The meeting of the Board of Directors To be held on ......GJ/SS December 2018 On QEC agenda for...

The meeting of the Board of Directors

To be held on Tuesday, 18 December 2018 at 10:00am

in the Fred & Ann Green Boardroom, Montagu Hospital

AGENDA Part I

Enclosures Time

1. Apologies for absence

(Verbal) 10:00am

2. Declarations of Interest Members of the Board and others present are reminded that they are required to declare any pecuniary or other interests which they have in relation to any business under consideration at the meeting and to withdraw at the appropriate time. Such a declaration may be made under this item or at such time when the interest becomes known.

(Verbal)

3. Actions from the previous meeting

Enclosure A

4. Implementation of the Strategy – Qii Presentation Marie Purdue – Director of Strategy & Transformation

Presentation 10:05am

Reports for assurance

5. Finance Report as at 30 November 2018 Jon Sargeant – Director of Finance

Enclosure B

10:35am

6. Performance Report – 30 November 2018 Led by David Purdue – Chief Operating Officer

Enclosure C

10:55am

7. People and Organisational Development Update – Staff Survey Action Plan Karen Barnard – Director of People and Organisational Development

Enclosure D 11:15am

8. Workforce Report Karen Barnard – Director of People and Organisational Development

Enclosure E 11:35am

9. Chairs Assurance Logs for Board Committee held 17 December Neil Rhodes – Chair of Finance and Performance Committee Linn Phipps – Chair of Quality & Effectiveness Committee

Enclosure F (to follow)

11:55am

10. Leadership & Organisational Development Framework Karen Barnard – Director of People and Organisational Development

Enclosure G 12:05pm

Suzy Brain England Chair of the Board

11. CQC Inspection Update

Richard Parker – Chief Executive

Verbal 12:20pm

Reports for information

12. Chair and NEDs’ Report Suzy Brain England – Chair

Enclosure H

12:35pm

13. Chief Executive’s Report Richard Parker –Chief Executive

Enclosure I

14. To note: Board of Directors Agenda Calendar Gareth Jones – Trust Board Secretary

Enclosure J

Minutes

15. To approve the minutes of the previous meeting held 27 November 2018

Enclosure K (to follow)

12:45pm

16. Any other business (to be agreed with the Chair prior to the meeting)

17. Governor questions regarding the business of the meeting

12:50pm

18. Date and time of next meeting

Date: 29 January 2019 Time: 10.00am Venue: Boardroom, DRI

19. Withdrawal of Press and Public

Board to resolve: That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

1:00pm

Action Notes

Meeting: Board of Directors

Date of meeting: 27 November 2018

Location: Boardroom, DRI

Attendees: SBE, RP, KB, JS, MP, SS, AC, PD, SM, LP, NR, KSm, KSu

Apologies: None

No. Minute No Action Responsibility Target Date Update

1. 18/9/51 QEC to deep dive cancelled operations.

DP December 2018 Deferred to

February 2019

Not yet due

2. 18/11/… Brexit Preparations - Ensure Brexit is incorporated in to consideration of risk by Board Committees.

Chairs QEC/F&P/ANCR

Future Committee meetings

Update to be provided at meeting.

3. 18/11/… Audit & Risk Committee (ARC) ToRs to be approved by Board.

GJ/KS January 2019 Not yet Due

No. Minute No Action Responsibility Target Date Update

4. 18/11/… Board to have clear sight of top clinical risks - Report to be taken to next QEC and update provided at next Board.

GJ/SS December 2018 On QEC agenda for 17.12.18 meeting

5. 18/11/…

P&OD - Leadership & Development

Framework to next meeting

- Agenda for Change - Details of cost to the Trust of transition of Band 1 staff to Band 2 through – To F&P

KB

KB/JS

December 2018

TBC

On Agenda Move to F&P Workplan

Date of next meeting: 18 December 2018 Action notes prepared by: K Sullivan Circulation: SBE, AC, NR, KB, MH, KSm, PD, DP, JS, SS, RP, LP, SM

Title Financial Performance – Month 8 - November 2018

Report to Board of Directors Date 18th December 2018

Author Jon Sargeant - Director of Finance

Alex Crickmar – Deputy Director of Finance

Purpose Tick one as appropriate

Decision

Assurance

Information X

Executive summary containing key messages and issues

The Trust’s surplus for month 8 (November 2018) was £295k, which is a small adverse variance against plan of £86k; however, this is a favourable variance against forecast (realistic case) of £779k in month. The cumulative position to the end of month 8 is an £11.6m deficit, which is £1.5m adverse to plan, but £811k favourable against forecast. The Trust needs to achieve a £6.6m deficit to deliver the year end control total, and therefore needs to achieve a better than break even position for the rest of the year. At per the previous F&P Committee and Board a forecast position was presented based on the Month 6 financial position. That forecast presented a range of year end scenarios including a best, realistic and worst case year-end financial position. However since this was presented two significant issues (which were previously reported to the Committee in the worst case scenario) have crystallised which impact on this position; the WOS (£3.2m) and depreciation (£3.9m). This currently shows that the Trust’s financial position before mitigations (and PSF) would be £10.4m away from delivering its control total. After mitigations have been deployed this reduces the gap to £7.1m in the realistic case. Therefore if the Trust was to change its forecast position at Month 9 per NHSi protocol, the Trust would need to show a £7.1m adverse variance to the control total. The Board is asked to support this change in forecast position if no further mitigations are identified before the Month 9 submission to NHSi.

Key questions posed by the report

Is the Trust Board assured by actions taken to bring the financial position back in line with plan?

How this report contributes to the delivery of the strategic objectives

This report relates to strategic aims 2 and 4 and the following areas as identified in the Trust’s

BAF and CRR.

F&P 1 - Failure to achieve compliance with financial performance and achieve financial plan and subsequent cash implications

F&P 3 - Failure to deliver Cost Improvement Plans in this financial year

F&P 19 - Failure to achieve income targets arising from issues with activity

F&P 13 - Inability to meet Trust's needs for capital investment

How this report impacts on current risks or highlights new risks

Update on risk relating to delivery of 2018/19 financial plan.

Recommendation(s) and next steps

The Board is asked to note:

The Trust’s surplus for month 8 (November 2018) was £295k, which is an adverse

variance against plan in month of £86k. The cumulative position to the end of month 8

is a £11.6m deficit, which is £1.5m adverse to plan and c.£811k favourable to forecast

(realistic case).

The progress in closing the gap on the Cost Improvement Programme.

The forecast scenarios presented including the risks set out in this paper.

The Board is asked to support the change in forecast position at Month 9 which will show a gap to control total (before PSF) of £7.1m and note that the Trust will continue to review and look for mitigations to improve this position.

1

FINANCIAL PERFORMANCE

P8 November 2018

2

Performance Indicator Performance Indicator Annual

Actual Actual Actual Actual Plan

£'000 £'000 £'000 £'000 £'000

I&E Perf Exc Impairments (281) 77 A (787) F 11,766 1,454 A (818) F 6,900 Employee Expenses 193 369 A 44 A 1,356 1,139 A 45 A 8383

Income (32,629) (709) F (823) F (249,679) 2,136 A (823) F (375,799) Drugs 63 (5) F (5) F 494 (27) F (5) F 700

PSF (previously STF) (1,624) 0 0 A (8,931) 0 0 A (16,238) Clinical Supplies 44 19 A 268 A 261 48 A 268 A 954

Donated Asset Income (15) 9 A 7 A (167) 23 A 7 A (285) Non Clinical Supplies 0 0 A 0 A 0 0 A 0 A 0

Operating Expenditure 32,858 811 A 106 A 261,362 (622) F 74 A 385,321 Non Pay Operating Expenses 231 460 A (130) F 2,135 83 A (130) F 4968

Pay 22,101 447 A (78) F 175,361 2,747 A (129) F 259,766 Income 207 16 A (20) F 1,131 (120) F (20) F 2820

Non Pay & Reserves 10,756 365 A 184 A 86,001 (3,369) F 203 A 125,555

Financing costs 1,115 (25) F (69) F 9,014 (61) F (69) F

I&E Perf Exc 16/17 STF & Donated

Asset Income(295) 86 A (779) F 1,477 A (811) F Total 737 860 A 157 A 5,379 1,123 A 157 A 17,825

Financial Sustainability Risk Rating Plan Actual

UOR 4 3 Performance Indicator Monthly Performance YTD Performance Annual

CoSRR 1 2 Actual Actual Plan

£'000 £'000

Cash Balance 2,242 2,242 1,900

All figures £m Capital Expenditure 344 2756 13,911

Non Current Assets 3,933 Actual Total in

Current Assets 9,169 WTE Post WTE

Current Liabilities -896

Non Current liabilities -555 Current Month 5527.53 5826.10

Total Assets Employed 11,599 Previous Month 5548.17 5856.22

Total Tax Payers Equity -11,599 Movement 20.64 30.12

WTE

F = Favourable A = Adverse

4. Other

Current

Balance

£'000

Variance to

budget

Variance to

Forecast

Funded

WTE

Plan

£'000

2,778

DONCASTER AND BASSETLAW TEACHING HOSPITALS NHS FOUNDATION TRUST

P8 November 2018

1. Income and Expenditure vs. Plan 2. CIPs

Monthly Performance

Variance to

Forecast

£'000

Variance to

budget

Variance to

budget

Monthly Performance

£'000

Balance

11,599 6,615

Variance to

Forecast

£'000

YTD Performance

£'000

Variance to

Forecast

Annual

£'000

Plan

£'000

9.68

3. Statement of Financial Position

Opening

109.88

100.20

5. Workforce

Agency

Movement

in

year

5898.20

-11.51

1604

5909.71

£'000

YTD Performance

209,108

49,291

-54,834

Plan

£'000

2,778

7607

Bank

WTE

£'000 £'000

Variance to

budget

205,175

40,122

-53,938

-80,550

110,861

198.37

198.17

-0.20

-81,105

122,460

-122,460 -110,861

3

The Trust’s surplus for month 8 (November 2018) was £295k, which is a small adverse variance against plan of £86k;

however, this is a favourable variance against forecast (realistic case) of £779k in month. The cumulative position to

the end of month 8 is an £11.6m deficit, which is £1.5m adverse to plan, but £811k favourable against forecast. The

Trust needs to achieve a £6.6m deficit to deliver the year end control total, and therefore needs to achieve a better

than break even position for the rest of the year.

The YTD income position at the end of Month 8 is £2,136k adverse to plan. The month 8 position was (£709k) and

(£822k) favourable to plan and forecast respectively. In month 8, NHS Clinical Income (including Non-PbR drugs) was

(£187k) and (£649k) ahead of plan and forecast (£3,304k adverse YTD to plan). Doncaster CCG has an adverse YTD

variance against the Trust’s plan of £853k (favorable variance against contract of £1,797k) and Bassetlaw CCG has a

favorable income variance of (£1,188k) against the Trust’s plan (£1,964k favorable against contract). Non NHS

Clinical Income and Other Income is (£522k) and (£174k) ahead of plan and forecast in month 8 and YTD (£1,168k)

favorable to plan. PSF is assumed at 100% in the position and CQUIN achievement at 95%.

The YTD expenditure position at the end of Month 8 is £622k favourable to plan, £74k adverse to forecast (with pay

£132k favourable to forecast and non-pay £207k adverse to forecast). The month 8 position was £811k and £106k

adverse to plan and forecast respectively. Non-PbR drugs were significantly lower than planned levels (c.£2.3m

which is offset by underperformance on income).

Capital expenditure YTD is £2,756k against the YTD plan of £7,607k, £4,851k behind plan (£3,229k behind plan excluding CT/HASU). YTD actuals against the revised plan are £3,658k behind plan (£2,037k behind plan excluding CT/HASU). The main reason for the slippage relates to estate schemes being behind plan by c.£3m including; fire enforcement works, electrical enhancements, and other minor estates works.

Income Group Annual

Budget

In Month

Budget

In Month

ActualYTD Budget YTD Actual

Commissioner Income -312,532 -26,549 -27,072 -523 F -209,244 -208,222 1,021 A

Drugs -24,089 -2,104 -1,769 335 A -16,491 -14,208 2,283 A

STF -16,238 -1,624 -1,624 0 F -8,931 -8,931 0 F

Trading Income -39,178 -3,267 -3,789 -522 F -26,081 -27,249 -1,168 F

Grand Total -392,037 -33,544 -34,253 -709 F -260,746 -258,610 2,136 A

Pay Award Adjustment 4,224 352 352 0 F 2,816 2,816 0 F

-387,813 -33,192 -33,901 -709 A -257,930 -255,794 2,136 A

In Month

VarianceYTD Variance

Income Group In Month

Actual

In Month

ForecastYTD Actual

YTD

Forecast

Commissioner Income -27,072 -26,388 -684 F -208,222 -208,145 -77 F

Drugs -1,769 -1,804 35 A -14,208 -13,636 -572 F

STF -1,624 -1,624 0 F -8,931 -8,931 0 F

Trading Income -3,789 -3,615 -174 F -27,249 -27,075 -174 F

Grand Total -34,253 -33,431 -822 F -258,610 -257,787 -823 F

Pay Award Adjustment 352 352 0 F 2,816 2,816 0 F

-33,901 -33,079 -822 F -255,794 -254,971 -823 F

In Month

VarianceYTD Variance

1. Executive Summary

4

The cash balance at the end of November was £2.2m against a plan of £2.8m. The main movements include; the receipt of Q4 STF funds (£2m more than anticipated), delayed capital expenditure (£4.8m), which is offset by PDC Dividend not received (£1.6m), loans not drawn down/repaid early (£6m), and movement in trade receivables/reduction in payables (£0.2m).The Trust’s financial plan assumed borrowing in 2018/19 of £6.6m. £2.6m has been drawn down year to date, and no loans were drawn-down in November, however the remaining £4m of loans will be drawn down in December. In November 2018, CIP savings of £737k (last month £954k) are reported, against a forecast of £894k, therefore a shortfall of £157k in month.

At per the previous F&P Committee and Board a forecast position was presented based on the Month 6 financial

position. That forecast presented a range of year end scenarios including a best, realistic and worst case year-end

financial position. However since this was presented two significant issues (which were previously reported to the

Committee in the worst case scenario) have crystallised which impact on this position; the WOS (£3.2m) and

depreciation (£3.9m). This currently shows that the Trust’s financial position before mitigations (and PSF) would be

£10.4m away from delivering its control total. After mitigations have been deployed this reduces the gap to £7.1m in

the realistic case.

The Trust’s surplus for month 8 (November 2018) was £295k, which is an adverse variance against plan of £86k,

however this position is a favourable variance against forecast (realistic case) of £779k in month. However the

Trust’s year to date financial position at Month 8 is £1,477k adverse compared to plan.

The Board is asked to note the changes in risks to the forecast position and the recovery plan to close the gap to the

control total. This currently shows that the Trust’s financial position before mitigations (and PSF) would be £10.4m

away from delivering its control total (best case - £6.5m gap; worse case - £13m gap). After mitigations have been

deployed this reduces the gap to £7.1m in the realistic case. Therefore if the Trust was to change its forecast position

at Month 9 per NHSi protocol, the Trust would need to show a £7.1m adverse variance to the control total. The

Board is asked to support this change in forecast position if no further mitigations are identified before the Month 9

submission to NHSi.

The Board is asked to note:

The Trust’s surplus for month 8 (November 2018) was £295k, which is an adverse variance against plan in

month of £86k. The cumulative position to the end of month 8 is a £11.6m deficit, which is £1.5m adverse to

plan and c.£811k favourable to forecast (realistic case).

The progress in closing the gap on the Cost Improvement Programme.

The forecast scenarios presented including the risks set out in this paper.

The Board is asked to support the change in forecast position at Month 9 which will show a gap to control total

(before PSF) of £7.1m and note that the Trust will continue to review and look for mitigations to improve this

position.

3. Recommendations

2. Conclusion

Title Business Intelligence Report

Report to Board of Directors Date 17th December 2018

Author David Purdue, Chief Operating Officer

Sewa Singh, Medical Director

Moira Hardy, Director of Nursing, Midwifery and AHPs

Karen Barnard, Director of People and Organisational Development


Decision

Assurance x

Information


This report highlights the key performance and quality targets required by the Trust to maintain NHSI compliance. The report focuses on the main performance area for NHSi compliance: Cancer 62 day classic, measured on average quarterly performance 4hr Access, measured on average quarterly performance 18 weeks measured on monthly performance against active waiters, performance measured

on the worst performing month in the quarter Diagnostics performance against key tests Infection control measures, C Diff and MRSA Bacteraemia The Quality report highlights the ongoing work with Care Groups and external partners to improve patient outcomes and a focus on mortality rates. The Workforce report identifies vacancy levels, agency spend and usage, sickness rates, appraisals and SET training.


Is the Trust maintaining performance against agreed trajectories with NHSi? Is the Trust providing a quality service for the patients? Are Governors assured by the actions being taken to maintain a quality service?


This report supports all elements of the strategic direction by identifying areas of good practice and areas where the Trust requires improvements to meet our expectations.


The corporate risks supported by this report are related to NHSi single oversight framework, especially in line with quality, patient experience, performance and workforce.


That the report be noted.

Performance Executive Summary Board of Directors November 2018

The performance report is against operational delivery in July, August and September 2018.

Provide the safest, most effective care possible

Monitor governance compliance is rated against 3 National targets, 4hr Access, Referral to

Treatment, which includes diagnostic waits and Cancer Targets. The targets are all monitored

quarterly, both 4hr access and cancer are averaged over the quarter but referral to treatment is

monitored each month of the quarter and must be achieved each month.

The report also highlights key local targets which ensure care is being provided effectively and safely

by the Trust.

Referral to Treatment

The Referral to Treatment Target, active waiters below 18 weeks set at 92%, the Trust has been

commissioned to achieve 89.1% by the end of March with no growth to the waiting list size.

Data currently unavailable

The activity plans to improve the waiting list position and RTT performance are being monitored

weekly through the PTL meeting and monthly at joint meetings with the CCG. Plans are in plan for

quarter 4 to ensure elective capacity for orthopaedics can be maintained in partnership with private

providers. In specialities with OPD waiting list pressures theatres in the first 14 days of January are

being converted to OPD sessions.

A revalidation of the waiting list will be undertaken in January/February.

4hr Access

The target is based on the number of patients who are treated within 4hrs of arrival into the

emergency department and set at 95% and reported quarterly as an average figure. This target is for

all urgent care provided by the Trust for any patient who walks in. We have 2 type 1 facilities, ED at

BDGH and DRI and 1 type 3 facility at MMH.

November Performance

Trust 92.9%

Quarter 3 92.55%

Year to date 93.18%

PSF for quarter 3 90.9%

The Trust saw 14059 attendances in November, which is 766 more than in November 2017. 995

patients failed to be treated in 4hrs, with the main breach reason was wait to see ED doctor/ ED

review which accounted for 56%.

The Trust has continued to see high attendance within the ED on both Doncaster and Bassetlaw

Teaching Hospital’s main sites equating to 7.2% increase on last November.

Streaming

Doncaster FDASS

The number of patients streamed directly from the front door in November was 13.9%.

NHSI Additional Reporting Requirements

Metric DRI BDGH

Total Discharges Weekday 145848 43860

Average Discharges Weekday 1473 443

Total Discharges Weekend 32403 7912

Average Discharges Weekend 327 80

Total Monday Attendances ED 30182 14984

Average Monday Attendances ED 305 151

Total Tues - Sunday Attendances ED 163776 78670

Average Tues - Sunday Attendances ED 1654 795

Total Elective (inc Daycase) Admissions Weekday 73841 22226

Average Elective (inc Daycase) Admissions Weekday 746 225

Total Elective (inc Daycase) Admissions Weekend 10776 1395

Average Elective (inc Daycase) Admissions Weekend 109 14

Total Non-Elective Admissions Weekday 71891 21100

Average Non-Elective Admissions Weekday 726 213

Total Non-Elective Admissions Weekend 21740 7026

Average Non-Elective Admissions Weekend 220 71

Total Non-Elective (GP) Admissions Monday 2918 351

Average Non-Elective (GP) Admissions Monday 29 4

Total Non-Elective (GP) Admissions Weekday(Inc Monday) 14727 1652

Average Non-Elective (GP) Admissions Weekday(Inc Monday) 149 17

Total Non-Elective (GP) Admissions Weekend 2415 159

Average Non-Elective (GP) Admissions Weekend 24 2

18.2% of all of DRI discharges take place at a weekend and 15.3% at BDGH

If the rest of the week was at the same level as Mondays then we would see an extra 175 patients a

week at DRI and an extra 113 patients at BDGH

A&E attendances on a Monday at DRI account for 15.6% of weekly activity rising to 16.0% at BDGH

Non Elective Admissions on a weekday that GP admissions account for is 20.5% of all Emergency

Admissions on a weekday at DRI but only 7.8% at BDGH.

When we move into the weekend this drops to 11.1% at DRI and 2.3% at BDGH

Cancer Performance

October

62 day performance 83%

The 62 day standard was not achieved by the Trust in October; slipping from 84.7% last month to 83.0%. The key issues remain problematic around complex pathways and shared breaches. The local pathway issues remain in Urology. There are specific issues around endometrial Cancers – there are 6 local breaches in gynaecology endometrial pathways. The system Cancer performance was reviewed by NHSE, key pathways were identified as requiring additional support. These included the prostate pathway, gynae and OMFS. The one stop prostrate clinic commenced on the 21st of November and the average time to get to MDT has fallen to 11 days. To improve gynaecology local performance the Trust will pilot a one stop post-menopausal bleed clinic, commencing on the 17th of December. The Trust has met with colleagues from STH to review the current arrangements for OMFS to

improve the local offer for patients. A pilot of Straight to test for colonoscopy has been partially funded by the Cancer Alliance for lower GI cancers, which will commence in April 2019. Two Week Wait Performance 93.1% The Capacity and Demand tool continues to be developed, providing a planning tool based on previous referral trends, activity and capacity. Care groups are now using the tool proactively in order to plan two week wait capacity. Since April there has been an overall increase of referrals for 2 week wait of 12%.

Stroke Performance

September

Direct admission 62%

CT within 1 hour 58%

In terms of exceptions, the key issues remain transfer from BDGH, patients not having stroke

symptoms on arrival and patients with complex needs requiring additional support in ED.

David Purdue Chief Operating Officer November 2018

DBTH PERFORMANCE REPORT – November 2018

1

Cancer Performance The following information relates to Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust performance in October. The action plan to improve 62 day and 2 week wait performance is now underway with expectations of improving performance over time. October Performance

Standard Local Performance % Position from Previous Month

TWW 93.2%

31 day 99.4%

62 day 83.0 %

31 day Sub – Surgery 100%

31 day Sub – Drugs 100%

31 day Sub – Other 100% N/A

62 day Screening 92.9%

62 day Con Upgrades 81.3%

Breast Symptomatic 96.2%

62 day Cancer performance The 62 day standard was not achieved by the Trust in October; slipping from 84.7% last month to 83.0%. The One Stop Prostrate Clinic pilot starts on both sites on 21 November. The key issues remain problematic around complex pathways and shared breaches. The local pathway issues remain in Urology. There are specific issues around endometrial Cancers – there are 6 local breaches in gynaecology endometrial pathways. The system Cancer performance was reviewed by NHSE, key pathways were identified as requiring additional support. These included the prostate pathway, gynae and OMFS. To improve gynaecology local performance the Trust will pilot a one stop post-menopausal bleed clinic. The Trust is meeting with colleagues from STH to review the current arrangements for OMFS to improve the local offer for patients.


2

The graphs below compare 62 day performance up to September at Doncaster and Bassetlaw compared with National performance.

Two Week Wait Performance

The October position for two week wait has continued to improve in month to 93.2%, moving from 91.1% last month, which is now compliant with the national target of 93%. Work with the Capacity and Demand tool continues to be improved. Care groups are continuing to use the tool proactively in order to plan two week wait capacity. Weekly PTL meetings with each specialty are ongoing to jointly track patient booking, pathways and to review breaches. These meetings now focus on both 2ww and 62 day breaches, with presentations for each service, denoting key issues and achievements. Both CCGs have been requested by NHSE to improve the communications to patients locally regarding the importance of keeping a TWW appointment.


3

TWW Performance by specialty for October

2ww

Non 2ww Symptomatic

Breast Referrals

31 Day - Classic

31Day Sub - Surgery

31 Day Sub - Drugs

31 Day Sub -

Palliative 62 Day - Classic

62 Day Screening

62 Day Consultant Upgrades

Operational Std 93% 93% 96% 94% 98% 94% 85% 90% TBA

Breast 100% 96,2% 100% 100% 100% 100% 100%

Gynaecology 91% 100% 36.4% 100%

Haematology 100% 100% 100% 100% 100%

Head & Neck 88.3% 100% 75%

Lower GI 92.8% 100% 100% 92.9% 0% 100%

Lung 100% 100% 69.2% 68.8%

Sarcoma 0%

Skin 89.8% 95.2% 100% 100%

Upper GI 97.8% 100% 70%

Urological 86% 100% 100% 100% 85.1% 76.9% EXCEPTIONS 62 DAY Breast, Haematology, Upper GI and Lung were compliant with the standard in October. The reasons for the breaches across all services were predominantly due to shared care pathways, complex diagnostic pathways or patient choice.


4

4hr Access Target In November 2018 the Trust achieved a performance 92.9 % against the 4hr access standard of

95%.

There was a 5.3% increase in November 2018 compared to November 2017. 7.3% at DRI and

7.2% at BDGH but a reduction at MMH, MIU.

995 patients failed to be treated within 4hrs which is 181 less than in November 2017. 58% of

the breaches were due to internal ED waits, 13% were due to bed waits and 19% were

unavoidable.

The PSF for quarter 3 is 90.9%, current Q3 performance is 92.55% with Year to date at 93.15%

The graphs below compare 4 hour access performance at Doncaster and Bassetlaw with

National performance

(NB: November updates not available)


5

EXCEPTIONS

In November, 995 (7.1%) patients failed to be treated in 4hrs; with the key issues being Waits to

see ED doctor, ED doctor reviews.

Streaming pathways continue to be reviewed at BDGH jointly with Notts Health Care FT and a

proposal developed for commissioners to review to improve front-door streaming alternative

pathways.

Children’s Observation Unit The COO has undertaken a review of the waiting times in the children’s observation unit. The unit currently operates a paper-based system logged in a book. Waiting times identified are not an accurate reflection of the times children actually spend waiting to be seen or to have a senior review. Multiple children are discharged on the hour; there is no timing of when children have a decision to be actively observed. The solution will be to develop the use of Symphony on the unit. This will ensure that accurate timings of children arriving, being assessed, having a senior review and a decision for either discharge or observation to be identified. The unit allows children to be assessed up to 8hrs prior to being admitted. Symphony will reduce the amount of time the nursing team are required to spend on administrative tasks.

Childrens Observation Unit


6

Referral to Treatment (RTT) November not available The Referral to Treatment Target, for active waiters below 18 weeks is set at 92%. DBTH

contract for 2018/19 expects the Trust to maintain the March position of 89.1% and the waiting

list size to be lower than it was at the end of March 2018.

The Trust position was 88.5% in October, an improvement against last month

The graphs below and on the next page show Doncaster and Bassetlaw’s performance up to September compared with the National picture:

The total number of Incomplete Pathways has increased by 301 between September and October with the number of incomplete pathways over 18 weeks increased by 219 hence the performance has very slightly increased. The number of new RTT periods in October was 2037 more than in September, with the result that the proportion of short waiters in the month has also gone up. There were 293 more admitted and 1432 more non-admitted clock stops in October than in September.

Octobers Specialty level RTT performance, against a target of 92%, can be found below:


7

Specialty Group Under 18 Weeks

18 Weeks & Over Total Percentage

General Surgery 2796 459 3255 85.9%

Urology 1527 192 1719 88.8%

T&O 5258 828 6086 86.4%

ENT 2820 621 3441 82.0%

Ophthalmology 2848 301 3149 90.4%

Oral Surgery 1721 110 1831 94.0%

General Medicine 1734 258 1992 87.0%

Cardiology 1788 227 2015 88.7%

Dermatology 1935 85 2020 95.8%

Thoracic Medicine 840 102 942 89.2%

Rheumatology 734 217 951 77.2%

Geriatric Medicine 198 44 242 81.8%

Gynaecology 1514 83 1597 94.8%

Others 3961 330 4291 92.3%

Trust Total 29674 3857 33531 88.5%

At the end of October 2018 there were 3 patients on Incomplete Pathways over 52 Weeks. No patients came to harm. Numbers have been validated.

Diagnostics In October the Trust achieved 99.5% against the 6ww Diagnostic Performance standard of 99%. There were 46 patient breaches in month, out of a total 9227 patients. (an increase of 1,438 patients against last month)

Waiters <6W Waiters >=6W Total Performance

Trust 9181 46 9227 99.50%

NHS Doncaster 6202 31 6233 99.50%

NHS Bassetlaw 2085 9 2094 99.57%

Most exam types continue to achieve the target in October, with 8 of the 13 diagnostic areas again achieving more than 99% and 7 of these 8 achieving 100%. Of note; MRI achieved 99.28% (10 breaches out of 1391 waiters) EXCEPTIONS: The 99% target was missed in 5 areas:


8

Audiology – 98.37% - 10 breaches out of 613 waiters (improved from 97,45% last month)

Nerve Conduction – 89.47% - 12 breaches from 114 waiters

Sleep Study – 93.33% - 1 breach in 15 waiters

Urodynamics – 82.76% - 10 breaches out of 58 waiters (improved from 77,42% last month)

Cystoscopy - 97.54% - 3 breaches out of 122 waiters (Slight improvement from 97,01%)

Stroke Performance in September The Trust level percentage for Direct Admission to the Stroke Unit was 62% in September against a 90% target.

Against a target of 48%, performance in September was compliant with the 1 Hour to scan standard at 58.3%. EXCEPTIONS For September, Direct Admissions, patients admitted over 10 hours were higher than usual at 9. Some of these related to pathway problems for patients presenting at Bassetlaw but also some patients whose symptoms were not immediately identified as possible strokes.


9

Category Sub Category Total

Direct Admission within

4 Hours Bassetlaw Doncaster Other Total Organisational Beds 2

Yes 8 21 1 30 Pathway 10

No 6 11 1 18 Staff Availability

Grand Total 14 32 2 48 Clinical

Patient

Presentation 2

Performance 57.1% 65.6% 50.0% 62.5% Patient Needs 4

Patient Choice Declined

Awaiting further validation

2. Scan within 1 Hour Target = 48% 2. Scan within 1 Hour

Category Sub Category Total

Scan 1 hr Bassetlaw Doncaster Other Total Organisational Scanner

Yes 9 17 2 28 Pathway 16

No 5 15 0 20 Staff Availability

Grand Total 14 32 2 48 Clinical Criteria

Performance 64.3% 53.1% 100.0% 58.3% Patient Needs 1

Patient

Presentation 2

Patient Choice Declined 1

Awaiting further validation

CCG

CCG

Cancelled Operations In November 1.01 % of Trust operations were cancelled this is a slight improvement against October’s performance. 17 operations were cancelled for clinical reasons and 35 for non-clinical reasons.

Indicator Standard Aug-

18 Sep-

18 Oct-

18 Nov-

18

Cancelled Operations (Total) 1.0% 1.67% 1.14% 1.13% 1.01%

Of which Theatre Cancellations - 1.50% 0.97% 0.88% 0.64%

Of which Non-Theatre Cancellations - 0.17% 0.17% 0.24% 0.37%

Cancelled Operations – 28 day standard 0 1 1 1 1

Non Clinical Theatre cancellations, November 2018


10

Insufficient time(11), Urgent case(2), Equipment issues(10), Bed availability(6),Staffing issues(5), Case note issue(1)

DNA and CNA Rates

In November the overall DNA rate across the Trust reduced again to 8.83% compared with the previous month’s position at 9.15%. The hospital cancellation rate reduced compared to previous months at 5.20%.

Delayed transfers of care DTOC Guidance has now been updated nationally which will provide more clarity and consistency when reporting.

Indicator June July Aug Sept Oct

Nov

Outpatients: DNA Rate Total 9.41% 9.78% 9.70% 9.90% 9.15% 8.83%

Outpatients: Hospital cancellation Rate

5.19% 5.66% 5.41% 5.41% 6.09% 5.20%


11

Indicator Standard Current Month Month ActualNHS England

%DBTHFT Month Peer Groups % DBTHFT Month Current Month

Month

Actual

(TRUST)

Month

Actual (DRI)

Month Actual

(BDGH)

Data Quality RAG

Rating

31 day wait for second or subsequent treatment: surgery 94.00% 100.00% 92.70% 100.00% 90.80% 100.00% % of patients achieving Best Practice Tariff Criteria Nov-18 48.60% 54.80% 0.00%

31 day wait for second or subsequent treatment: anti cancer drug

treatments98.00% 100.00% 99.40% 100.00% 100.00% 100.00%

31 day wait for second or subsequent treatment: radiotherapy 94.00% 100.00% 97.60% 100.00% Not Available 100.00% 36 hours to surgery Performance 57.14% 58.06% 50.00%

62 day wait for first treatment from urgent GP referral to treatment 85.00% 83.00% 78.40% 83.00% 76.45% 83.00% 72 hours to geriatrician assessment Performance 82.86% 90.32% 25.00%

62 day wait for first treatment from consultant screening service

referral90.00% 92.90% 87.30% 92.90% 81.40% 92.90% % of patients who underwent a falls assessment 94.00% 94.00% 100.00%

31 day wait for diagnosis to first treatment- all cancers 96.00% 99.40% 96.60% 99.40% 95.70% 99.40% % of patients receiving a bone protection medication assessment 91.00% 94.00% 75.00%

Two week wait from referral to date first seen: all urgent cancer

referrals (cancer suspected)93.00% 93.20% 92.30% 93.20% 89.60% 93.20%

Two week wait from referral to date first seen: symptomatic breast

patients (cancer not initially suspected)93.00% 96.20% 91.90% 96.20% 95.50% 96.20%

Infection Control C.Diff4 Per Month -

45 full yearM

Infection Control MRSA 0 L

HSMR (rolling 12 Months) 100 N Aug-18

Never Events 0 L Nov-18

VTE 95.0% N Oct-18

Avoidable Pressure Ulcers Cat 3&4 21 Full Year L Nov-18

Ambulance Handovers Breaches -Number waited over 15 & Under 30

Minutes821 Falls that result in a serious Fracture

2 Per Month 23

full YearL

Ambulance Handovers Breaches-Number waited over 30 & under 60

Minutes34

Ambulance Handovers Breaches -Number waited over 60 Minutes 2

Proportion of patients scanned within 1 hour of clock start (Trust) 48.00% 58.30%

Proportion of patients directly admitted to a stroke unit within 4 hours

of clock start (Trust)90.00% 62.50%

Percentage of eligible patients (according to the RCP guideline

minimum threshold) given thrombolysis (Trust)20.00% 6.30%

Percentage of patients treated by a stroke skilled Early Supported

Discharge team (Trust)40.00% 69.20%

Percentage of those patients who are discharged alive who are given a

named person to contact after discharge (Trust)95.00% 87.20%

Implementation of Stroke Strategy - TIA Patients Assessed and Treated

within 24 Hours60.00% November 68.00%

Cancelled Operations 0.80% 1.01%

Cancelled Operations-28 Day Standard 0 1

Out Patients: DNA Rate 8.83% 7.82% 9.70% August 7.14% 9.70% August

Still looking @ data sources for obtaining this information

Data Quality RAG

Rating

At a Glance November 2018 (Month 8)Doncaster & Bassetlaw Teaching Hospital NHS Foundation Trust

NHS England

BenchmarkingPeer Group Benchmarking

Mo

nit

or

Co

mp

lian

ce F

ram

ew

ork

Direction of

travel

compared to

previous

Month

Frac

ture

d N

eck

of

Fem

ur

Indicator

October

0.00%

October October

Best Practice Criteria

Nov-18

A&E: Maximum waiting time of four hours from arrival / admission /

transfer / discharge (Trust)92.90% 87.60%

% of Patients waiting less than 6 weeks from referral for a diagnostics

test99.00% October 99.50% 97.30%

Maximum time of 18 weeks from point of referral to treatment-

incomplete pathway92.00% October 88.50% 86.70%

95.00% November

UCL: 796 & LCL: 659

UCL: 122 & LCL: 56

UCL: 29 & LCL: 2

September

Mortality-Deaths within 30 days of procedure 8.10% 9.10%

Data Quality RAG

Rating

Complaints received (12 Month Rolling)

Current Month Month Actual

Nov-182

92.90% November 85.88% 92.90% November

Safe

88.00% September 82.46%

99.40% 99.40% September

95.5%

0

88.00% September

0

94.17

0

IndicatorStandard (Local,

National Or Monitor)

95.60%

Am

bu

lan

ce H

and

ove

r Ti

me

s

October

1

Catheter UTI Snap shot audit

Month Actual

Nov-18

0.96%

Effe

ctiv

e

Emergency Readmissions within 30 days (PbR Methodology) October 6.49%

Stro

ke

September

The

atre

s &

Ou

tpat

ien

ts

November

Out Patients: Hospital Cancellation Rate 5.20%Clinical Negligence Scheme for Trusts (CNST)

No Benchmarking available

No Benchmarking available - data not submitted to Secondary Uses Service by all Trusts

412

89.0%

9

Complaints Performance

668

Co

mp

lain

ts &

Cla

ims

Wo

rkfo

rce

Oct-18

Concerns Received (12 Month Rolling)

SSNAP performance for December to March improved to A rating.

Data Quality RAG

Rating

AppraisalsNovember

Indicator Current Month

7.10% 6.40% July 7.80% 6.40% July

78.85%

SET Training 81.70%

Liabilities to Third Parties Scheme (LTPS) 0

Claims per 1000 occupied bed days 0.4

Indicator Current Month YTD (Cumulative)

Monitor Compliance Framework: Cancer - Graphs - October 2018 (Month 7)

Monitor Compliance Framework: A&E - Graphs - November (Month 8)

Monitor Compliance Framework: 18 Weeks & Diagnostics -October (Month 7)

Stroke - Graphs September 2018 (Month 6)

Mr S Singh

Mrs M Hardy

Serious Incidents: We reported 7 SI's in month, one of which was due to a serious fall. The other 6 are being scoped as SI's at this stage.

Executive Summary - Safety & Quality - November 2018 (Month 8)

HSMR: In month HSMR has returned to better than expected at 94.2 despite a rebasing of HSMR in August. Our rolling 12 month HSMR is 94.0 and crude mortality

remains stable.

Fractured Neck of Femur: There has been a small inprovement in achievement of Best Pratice Tariff whilst mortality risk remains better than expected

Executive Lead:

Executive Lead:

C-Diff The rate is above that of the same period last year and lower than the year to date position and national trajectory

Fall resulting in significan harm: The rate is higher than the same period last year the YTD position

Hospital Acquired Pressure Ulcers: The rate for October is lower compared to last year for the same month, with no HAPU's being reported in month. YTD data however is higher when

compared to last year.

Complaints and Concerns The number of complaints and concerns remains within normal variation. Complaints response times with in timescale has dropped slightly to 89%.

Friends & Family Test: There has been a further deterioration in the response rates for inpatients and this has been addressed with the Divisions. ED has seen a slight

improvement. Positivity of responses continues to be better than the national average for both inpatients and ED.

2015 2016 2017 2018

January 116.80 99.21 94.86 93.92

February 99.94 97.73 105.44 84.21

March 90.54 97.37 82.66 87.34

April 105.91 88.50 85.36 97.95

May 101.15 96.60 82.88 92.93

June 80.27 93.67 89.99 90.31

July 92.56 97.73 96.09 111.62

August 100.27 87.52 73.78 94.17

September 90.26 95.34 87.30

October 90.29 88.66 98.57

November 88.98 82.30 88.02

December 82.30 93.52 99.02

Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18

Trust 1.99% 2.11% 1.52% 1.48% 1.46% 1.23% 1.06% 1.37% 1.35% 1.26% 1.33% 1.35%

Donc 2.13% 2.29% 1.63% 1.46% 1.51% 1.33% 1.08% 1.40% 1.47% 1.27% 1.43% 1.44%

Bass 1.94% 1.86% 1.45% 1.87% 1.60% 1.19% 1.23% 1.53% 1.10% 1.43% 1.23% 1.27%

HSMR Trend (monthly) Crude Mortality (monthly) - Oct 2018 (Month 7)(number of deaths/number of patient discharged)

Hospital Standardised Mortality Ratio (HSMR) - Aug 2018 (Month 5)

Overall HSMR (Rolling 12 months) HSMR - Non-elective Admission (Rolling 12 months) HSMR - Elective Admission (Rolling 12 months)

93.55

86

88

90

92

94

96

98

Oct

16

- S

ep 1

7

No

v-1

6 -

Oct

-17

Dec

16

- N

ov

17

Jan

17

- D

ec 1

7

Feb

17

- J

an 1

8

Mar

17

- Fe

b 1

8

Ap

r 1

7 -

Mar

18

May

17

- A

pr

18

Jun

17

- M

ay 1

8

Jul 1

7 -

Ju

n 1

8

Au

g 1

7 -

Ju

l 18

Sep

17

- A

ug

18

93.94

86

88

90

92

94

96

98

Oct

16

- S

ep 1

7

No

v-1

6 O

ct-1

7

Dec

16

- N

ov

17

Jan

17

- D

ec 1

7

Feb

17

- J

an 1

8

Mar

17

- F

eb 1

8

Ap

r 1

7 -

Mar

18

May

17

- A

pr

18

Jun

17

- M

ay 1

8

Jul 1

7 -

Jun

18

Au

g 1

7 -

Ju

l 18

Sep

17

- A

ug

18

55.59

40

50

60

70

80

90

100

Oct

16

- S

ep 1

7

No

v-1

6 O

ct-1

7

Dec

16

- N

ov

17

Jan

17

- D

ec 1

7

Feb

17

- J

an 1

8

Mar

17

- F

eb 1

8

Ap

r 1

7 -

Mar

18

May

17

- A

pr

18

Jun

17

- M

ay 1

8

Jul 1

7 -

Ju

n 1

8

Au

g 1

7 -

Ju

l 18

Sep

17

- A

ug

18

1.0%

1.2%

1.4%

1.6%

1.8%

2.0%

2.2%

Dec

/17

Jan

/18

Feb

/18

Mar

/18

Ap

r/1

8

May

/18

Jun

/18

Jul/

18

Au

g/1

8

Sep

/18

Oct

/18

No

v/1

8

Crude Mortality (Trust)

0.5%

1.5%

2.5%

Dec

/17

Jan

/18

Feb

/18

Mar

/18

Ap

r/1

8

May

/18

Jun

/18

Jul/

18

Au

g/1

8

Sep

/18

Oct

/18

No

v/1

8

Crude Mortality (BDGH)

1.0%

1.5%

2.0%

2.5%

Dec

/17

Jan

/18

Feb

/18

Mar

/18

Ap

r/1

8

May

/18

Jun

/18

Jul/

18

Au

g/1

8

Sep

/18

Oct

/18

No

v/1

8

Crude Mortality (DRI)

NHFD Best Practice Pathway Performance - Nov 2018 (Month 8)

Best Practice Criteria Performance 36 Hours to Surgery Performance 72 hours to Geriatrician Assessment Performance

Bone Protection Medication Assessment Falls Assessment Performance

Relative Risk Mortality (HSMR) - Fractured Neck of Femur

Rolling 12 month

0%

20%

40%

60%

80%

100%

120%

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

% achieving best practice tariff criteria (Trust) % achieving best practice tariff criteria (DRI)

% achieving best practice tariff criteria (BDGH)

40%

60%

80%

100%

Dec

/17

Jan

/18

Feb

/18

Mar

/18

Ap

r/1

8

May

/18

Jun

/18

Jul/

18

Au

g/1

8

Sep

/18

Oct

/18

No

v/1

8

Trust DRI BDGH

40%

60%

80%

100%

Dec

/17

Jan

/18

Feb

/18

Mar

/18

Ap

r/1

8

May

/18

Jun

/18

Jul/

18

Au

g/1

8

Sep

/18

Oct

/18

No

v/1

8

Trust DRI BDGH

60%

70%

80%

90%

100%

Dec

/17

Jan

/18

Feb

/18

Mar

/18

Ap

r/1

8

May

/18

Jun

/18

Jul/

18

Au

g/1

8

Sep

/18

Oct

/18

No

v/1

8

Trust DRI BDGH

60%

70%

80%

90%

100%

Dec

/17

Jan

/18

Feb

/18

Mar

/18

Ap

r/1

8

May

/18

Jun

/18

Jul/

18

Au

g/1

8

Sep

/18

Oct

/18

No

v/1

8

Trust DRI BDGH

85.56

83.25

94.4

40

50

60

70

80

90

100

110

120

130

140

Sep

/17

Oct

/17

No

v/1

7

Dec

/17

Jan

/18

Feb

/18

Mar

/18

Ap

r/1

8

May

/18

Jun

/18

Jul/

18

Au

g/1

8

Trust DRI BDGH

Current YTD reported SI's (April-Sep 18) 35 48

Current YTD delogged SI's (April-Sep 18) 0 27

Serious Incidents - Nov 2018 (Month 8)(Data accurate as at 06/12/2018)

Please note: At the time of producing this report the number of serious incidents reported are prior to the RCA process being completed.

Overall Serious Incidents

Number reported SI's (Apr-Sep 17)

Number delogged SI's (Apr-Sep 17)

Themes

0.00

0.02

0.04

0.06

0.08

0.10

0.12

0.14

0.16

Dec

/17

Jan

/18

Feb

/18

Mar

/18

Ap

r/1

8

May

/18

Jun

/18

Jul/

18

Au

g/1

8

Sep

/18

Oct

/18

No

v/1

8

Pressure Ulcers - Category 3 & 4 (HAPU)

Pressure Ulcers HAPU 3 & 4 per 1000 occupied bed days

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

Dec

/17

Jan

/18

Feb

/18

Mar

/18

Ap

r/1

8

May

/18

Jun

/18

Jul/

18

Au

g/1

8

Sep

/18

Oct

/18

No

v/18

Care Issues

Care Issues per 1000 occupied bed days

0

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

0.09

Dec

/17

Jan

/18

Feb

/18

Mar

/18

Ap

r/1

8

May

/18

Jun

/18

Jul/

18

Au

g/1

8

Sep

/18

Oct

/18

No

v/1

8

Serious Falls

Serious Falls per 1000 occupied bed days

0

0.1

0.2

0.3

0.4

0.5

0.6

Dec

/17

Jan

/18

Feb

/18

Mar

/18

Ap

r/1

8

May

/18

Jun

/18

Jul/

18

Au

g/1

8

Sep

/18

Oct

/18

No

v/1

8

Serious Incidents per 1000 occupied bed days

Reported Si's per 1000 occupied bed days Reported Si's per 1000 occupied bed days - Previous years performance

0

2

4

6

8

10

12

14

Ap

r/1

8

May

/18

Jun

/18

Jul/

18

Au

g/1

8

Sep

/18

Oct

/18

No

v/1

8

Number Serious Incidents Reported (Trust & Care Group)

Clinical Speciality Services Medicine

Surgery & Cancer Children & Families

Number Reported SI's Number Reported SI's - Previous years performance

Standard Q1 Q2 Oct Nov YTD

2018-19 Infection Control - C-diff 39 Full Year 6 2 3 2 13

2017-18 Infection Control - C-diff 40 Full Year 8 8 5 1 22

2018-19 Trust Attributable 12 0 0 0 0 02017-18 Trust Attributable 12 1 1 1 0 3

Standard Q1 Q2 Oct Nov YTD

2018-19 Serious Falls 10 Full Year 1 1 2 1 5

2017-18 Serious Falls 6 Full Year 0 1 2 0 3

Standard Q1 Q2 Oct YTD

2018-19 Pressure Ulcers 21 Full Year 7 12 0 19

2017-18 Pressure Ulcers 27 Full Year 5 7 4 16

Monitor Compliance Framework: Infection Control C.Diff - Nov 2018 (Month 8)

(Data accurate as at 06/12/2018)

Pressure Ulcers & Falls that result in a serious fracture - Nov 2018 (Month 8)

(Data accurate as at 06/12/2018)

Please note: At the time of producing this report the number of serious falls reported

are prior to the RCA process being completed.

0

10

20

30

40

50

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Jan

Feb

Mar

C-diff 2018-19

2018-19 C-diff Cumulative total 2017-18 C-diff Cumulative total Standard

02468

1012

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Falls that result in a serious fracture

2018-19 Falls Cumulative Total 2017-18 Falls Cumulative Total Standard

0

10

20

30

40

50

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Pressure Ulcers (Ungradeable, Cat 3 & Cat 4)

2018-19 Pressure Ulcer Cumulative Total 2017-18 Pressure Ulcer Cumulative Total Standard

0

5

10

15

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Jan

Feb

Mar

Trust Attributable C-diff 2018-19

2018-19 Trust Attributable Cumulative Total 2017-18 Trust Attributable Cumulative Total Standard

-2

0

2

4

6

8

No

v

Dec Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

Pressure Ulcers (Ungradeable, Cat 3 & Cat 4)

Mean UCL LCL

Safe Effective Caring Responsive Well Led

Division Matron Ward

No of

Funded

Beds

CHPPD Variance Total score Total score Total score Total scoreQM total

scoreWork-force Quality

Surgery & Cancer B5 30.7 6.6 93% 0.5 1.5 0.0 2.0 4.0

B6 16 7.8 98% 3.0 0.0 0.0 2.0 5.0

AH St Leger 35 6.6 97% 0.5 1.0 1.0 1.0 3.5

AH 1&3 23 8.5 95% 1.5 0.0 1.0 2.0 4.5

20 27 4.8 94% 2.0 0.5 2.5 0.5 5.5

21 27 5.0 100% 2.5 0.5 0.0 1.5 4.5

S10 20 5.5 94% 1.5 0.0 1.0 1.5 4.0

S11 19 6.1 108% 0.5 0.0 0.0 3.0 3.5

S12 20 5.9 101% 1.0 2.5 1.5 2.5 7.5

SAW 21 8.2 97% 1.0 0.0 2.0 2.0 5.0

98%

Medicine JC A4 24 6.7 104% 0.0 1.0 1.0 1.5 3.5

JC C1 16 6.2 94% 0.0 0.5 0.0 2.5 3.0

JC CCU/C2 18 6.6 102% 1.0 1.0 1.0 1.5 4.5

JC ATC 21 8.9 104% 2.0 2.5 0.0 2.0 6.5

SS AMU 40 7.8 90% 2.5 0.5 3.0 1.0 7.0

MT FAU 16 8.0 97% 1.0 1.0 1.0 1.5 4.5

AW 16 24 8.3 112% 2.5 0.0 1.5 1.5 5.5

AW 17 24 5.6 97% 2.0 0.5 1.0 2.0 5.5

18 Haem 12 7.8 103% 4.0 0.5 0.0 1.5 6.0

18 CCU 12 7.5 97% 2.0 0.0 0.0 1.5 3.5

24 24 5.5 102% 0.5 0.0 2.0 1.5 4.0

25 16 7.9 130% 0.5 1.0 2.5 1.0 5.0

Respiratory unit 56 6.6 110% 2.0 0.5 2.5 0.5 5.5

32 18 6.2 100% 1.0 1.0 1.5 1.5 5.0

MT Mallard 16 8.4 101% 2.5 0.5 0.5 2.0 5.5

MT Gresley 32 5.8 99% 0.0 2.5 1.0 1.5 5.0

MT Rehab 2 19 6.3 114% 2.5 1.0 0.0 1.5 5.0

MT Rehab 1 29 5.2 103% 1.0 1.0 0.0 1.0 3.0

103%

Clinical Speciality Services ITU DRI 20 25.8 81% 2.0 2.5 0.0 1.5 6.0

ITU BDGH 6 28.1 90% 0.0 2.5 0.0 0.5 3.0

83%

Children and Families AB SCBU 8 10.5 100% 0.0 0.0 0.0 0.5 0.5

AB NNU 18 8.4 93% 1.0 1.0 0.0 0.0 2.0

AB CHW 18 7.6 90% 0.5 0.5 0.0 1.0 2.0

AB COU 12 9.9 97% 0.5 0.5 0.0 1.0 2.0

TB G5 24 7.3 76% 2.5 0.0 2.0 0.5 5.0

JH M1 26 8.6 94% 0.0 2.5 2.0 1.0 5.5

JH M2 18 9.1 86% 1.0 2.5 1.0 1.0 5.5

SR CDS 14 41.2 86% 1.0 1.0 1.0 1.0 4.0

JH A2 18 8.2 88% 2.0 2.5 1.0 0.5 6.0

KC A2L 6 27.9 98% 1.0 0.5 2.0 1.0 4.5

90%

Hard Truths - Nov 2018 (Month 8)(Data accurate as at 13/12/2018)

Planned v Actual ProfileThe workforce data submitted to UNIFY provides the actual

hours worked in November 2018 by registered nurses or

midwives, and health care support workers compared to the

planned hours. The Trusts overall planned versus actual

hours worked was 97% in November 2018; slightly lower than

recent months. There are no wards flagging as red on quality.

The data for November 2018 demonstrates that the actual

available hours compared to planned hours were;

20 wards (50%) within 5% of the planned staffing level, 3 less

than last month

10 wards (20%) between 5-10% of planned staffing levels, 2

more than last month.

3 wards (12.5%) <10% higher than planned staffing level, 2

less than last month.

7 wards (10%) >10% lower than planned staffing level, 3 less

than last month.

The wards where there were deficits in excess of 10% of the

planned hours are ITU at BDGH, DCC, CHW G5, M2, CDS and

A2. ITU at BDGH had some periods of reduced occupancy so

staff were redeployed to wards and departments to optimise

safe staffing needs, as did DCC, but the roster gaps were also

part of a vacancy rate which is being recruited to. G5

experienced sickness, but along with Maternity requires a

revision of the roster plan to optimise the use of staff

resources.

The wards with greater than 10% of actual staffing over

planned staffing are Ward 25, Stroke Unit and Rehab 1.

Escalation beds opened due to demand on Ward 25

impacting on staffing plans, with enhanced care needs

impacting also. Enhanced care impacted on Rehab 1 and the

Stroke Unit.

Registered

midwives/

nurses

Care Staff Overall

4.86 3.44 8.30

4.49 3.38 7.87

2.39 3.27 5.65

4.43 3.39 7.81TRUST

The data for November 2018 shows a similar position across DRI and BDGH sites, with a slight improved CHPPD rate overall. The trends

are monitored through the Quality and Effectiveness Committee.

Care Hours Per Patient Day (CHPPD) - Nov 2018 (Month 8)(Data accurate as at 13/12/2018)

Utilising actual versus planned staffing data submitted to UNIFY and applying the CHPPD calculation the care hours for October 2018 are

shown below

Site Name

BASSETLAW HOSPITAL

DONCASTER ROYAL INFIRMARY

MONTAGU HOSPITAL

Month

`

2016/17 0

2

1

0

0

3

1

3

0

0

0

4

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD

2018/19 10 7 10 6 8 11 11 9 72

2017/18 8 12 10 18 11 17 9 9 9 6 6 9 116

2018/19 2 6 1 1 7 0 2 0 19

2017/18 2 3 1 1 2 1 1 4 1 2 4 2 20

Number referred for

investigation

YTD

Outcomes

YTD

Complaints & Claims - Nov 2018 (Month 8)(Data accurate as at 06/12/2018

Complaints

Complaints - Resolution Perfomance (% achieved resolution within timescales)

Parliamentary Health Service Ombusdman (PHSO)

Number of cases referred

for investigationNumber Currently Outstanding

Nov-18 3 5

8 Outstanding

2017/18 7

Fully / Partially Upheld

Not Upheld

No further Investigation

Case Withdrawn

Not Investigated

Outstanding

2018/19 7

Fully / Partially Upheld

Not Upheld

No further Investigation

Case Withdrawn

Outstanding

Please note: Performance as a percentage is calculated on the cases replied and overdue, compared to the due date. Any current

investigations that have not gone over deadlines are excluded data.

Claims

Clinical Negligence Scheme for Trusts (CNST) Not including

Disclosures

Liabilities to Third Parties Scheme (LTPS)

Please note: At the time of producing this report the number of claims reported are provisional and prior to validation

Nov 2018 Complaints Received

Risk Breakdown

Low Risk

Moderate Risk

High Risk

Year to Date Complaints Received

Risk Breakdown

0

10

20

30

40

50

60

70

80

Ap

r 2

01

4

Jun

20

14

Au

g 2

01

4

Oct

20

14

Dec

20

14

Feb

20

15

Ap

r 2

01

5

Jun

20

15

Au

g 2

01

5

Oct

20

15

Dec

20

15

Feb

20

16

Ap

r 2

01

6

Jun

20

16

425

83

428

56

430

70

431

32

431

91

432

52

433

13

433

74

Complaints Received

Complaints Mean UCL LCL

0

20

40

60

80

100

120

Ap

r 2

01

4

Jun

20

14

Au

g 2

01

4

Oct

20

14

Dec

20

14

Feb

20

15

Ap

r 2

01

5

Jun

20

15

Au

g 2

01

5

Oct

20

15

Dec

20

15

Feb

20

16

Ap

r 2

01

6

Jun

20

16

42

58

3

42

85

6

43

07

0

43

13

2

43

19

1

43

25

2

43

31

3

43

37

4

Concerns Received

Concerns Mean UCL LCL

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Dec

/17

Jan

/18

Feb

/18

Mar

/18

Ap

r/1

8

May

/18

Jun

/18

Jul/

18

Au

g/1

8

Sep

/18

Oct

/18

No

v/1

8

Complaints Resolution Performance

0.00

0.20

0.40

0.60

0.80

1.00

Dec

/17

Jan

/18

Feb

/18

Mar

/18

Ap

r/1

8

May

/18

Jun

/18

Jul/

18

Au

g/1

8

Sep

/18

Oct

/18

No

v/1

8

Number of Claims per 1000 Occupied bed days

Claims per 1000 occupied bed days Claims per 1000 occupied bed days - Previous years performance

Accident & Emergency

Please note: At the time of producing this report no further benchmarking data is available from NHS England.

Friends & Family - Oct 2018 (Month 7)(Data accurate as at 07/12/2018)

Inpatients

Please note: At the time of producing this report no further benchmarking data is available from NHS England.

0%5%

10%15%20%25%30%35%

No

v/1

7

Dec

/17

Jan

/18

Feb

/18

Mar

/18

Ap

r/1

8

May

/18

Jun

/18

Jul/

18

Au

g/1

8

Sep

/18

Oct

/18

Response Rates (%)

Trust Rate NHS England Yorkshire & the Humber

0.930.940.950.960.970.980.99

1

No

v/1

7

Dec

/17

Jan

/18

Feb

/18

Mar

/18

Ap

r/1

8

May

/18

Jun

/18

Jul/

18

Au

g/1

8

Sep

/18

Oct

/18

Likely to recommend (%)


0%

2%

4%

6%

8%

10%

12%

14%

No

v/1

7

De

c/1

7

Jan

/18

Feb

/18

Mar

/18

Ap

r/1

8

May

/18

Jun

/18

Jul/

18

Au

g/1

8

Sep

/18

Oct

/18

Response Rates (%)


0.75

0.8

0.85

0.9

0.95

1

No

v/1

7

Dec

/17

Jan

/18

Feb

/18

Mar

/18

Ap

r/1

8

May

/18

Jun

/18

Jul/

18

Au

g/1

8

Sep

/18

Oct

/18

Likely to recommend (%)


Executive summary - Workforce - November 2018 (Month 8)

Sickness absence October and November has seen an increase in sickness absence as typically occurs at this time of year (ref the previous year's data). However there contimnues to be a reduction in long term absences, albeit a small rise in over 6 month absences in November. Appraisals The Trusts appraisal completion rate on the attached has maintained at 78.85% as at the end of November 2018 following the end of the appraisal season. A further report indicates that rates have improved to 80.65% - the analysis by Division is now required. SET Disappointingly SET compliance has increased slightly to 81.7% as at the end of November following the small reduction last month. Specific focus continues on topics where compliance rates are lower and with the new Divisions where compliance rates are low and is included in the CQC action plans. Staff in post Please see attached tab covering staff in post by staff group. Vacancy rates are provided to both Finance & Performance and Quality & Effectiveness Committees.

Workforce: Sickness Absence - November (Month 8)

Division & Directorate Sickness Absence - Noember 2018 (Q3)

RAG: Below Trust Rate - Above Target - Above Trust Rate

Abs Rate = 4.33% LT Abs Rate = 2.63%

Days Lost = 7871.567,319.32

Sickness Absence Occurences

0%

1%

2%

3%

4%

5%

6%

7%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Target - 3.50% % 17/180

5

10


Over 12 mths12 Months+ 17/18

0

10

20

30


Over 6 Months6 Months+ 17/18

0

100

200

300


Over 28 Days28Days - 6mths 17/18

0

100

200

300


BF +1000BF +1000 17/18

Long term / Short Term

0.00%0.50%1.00%1.50%2.00%2.50%3.00%3.50%

Apr

May Jun Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

Short term%

Long Term%

Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate

Doncaster & Bassetlaw Teaching Hospitals NHS FT 6966.07 4.30% 6852.91 4.09% 6610.26 4.08% 7244.35 4.34% 6993.67 4.16% 6462.26 3.96% 7319.32 4.33% 7293.52 4.46% 56,668.61 4.29%

Chief Executive Directorate 14.00 2.67% 27.76 5.12% 18.80 3.58% 0.00 0.00% 2.00 0.36% 0.91 0.17% 0.00 0.00% 0.00 0.00% 63.47 1.50%

Children & Families Division 840.01 4.65% 851.44 4.60% 608.47 3.43% 769.74 4.21% 843.46 4.62% 666.99 3.77% 881.61 4.79% 935.22 5.26% 6,653.48 4.60%

Clinical Specialist Division 1932.19 4.51% 1682.42 3.81% 1650.39 3.88% 2000.43 4.57% 1854.48 4.22% 1768.63 4.16% 2076.30 4.72% 2082.55 4.91% 15,293.13 4.42%

Directorate Of Strategy & Improvement 0.00 0.00% 2.00 1.72% 0.00 0.00% 1.00 0.80% 0.00 0.00% 0.00 0.00% 0.00 0.00% 0.00 0.00% 3.00 0.29%

Estates & Facilities 818.11 5.76% 772.80 5.24% 745.79 5.21% 878.47 5.94% 811.97 5.57% 895.99 6.37% 917.08 6.37% 790.93 5.66% 6,643.69 5.78%

Executive Team Board 0.00 0.00% 1.00 0.08% 2.00 0.16% 0.00 0.00% 0.00 0.00% 0.00 0.00% 3.00 0.11% 30.60 1.13% 36.60 0.24%

Finance & Healthcare Contracting Directorate 80.84 2.96% 42.00 1.52% 72.54 2.74% 31.07 1.16% 15.60 0.58% 12.00 0.48% 14.92 0.58% 25.84 1.01% 300.16 1.42%

IT Information & Telecoms Directorate 71.46 2.22% 113.84 3.46% 143.69 4.46% 141.81 4.20% 125.97 3.72% 162.66 4.91% 103.48 3.04% 122.04 3.72% 952.29 3.59%

Medical Director Directorate 3.60 0.64% 21.14 3.62% 23.40 4.22% 23.15 4.15% 23.15 4.15% 10.45 1.94% 0.00 0.00% 12.45 2.23% 117.94 2.63%

Medicine Division 1901.44 4.53% 1967.12 4.49% 1750.43 4.14% 1832.66 4.20% 1783.53 4.07% 1655.56 3.90% 1802.19 4.09% 1824.09 4.28% 14,735.02 4.27%

Nursing Services Directorate 74.84 4.27% 58.53 3.27% 86.20 4.97% 87.04 4.81% 73.20 3.98% 39.60 2.27% 23.80 1.29% 70.80 3.79% 515.01 3.58%

People & Organisational Directorate 118.60 3.97% 124.76 4.00% 112.95 3.79% 93.69 3.01% 2.65 0.09% 6.60 0.21% 50.41 1.53% 68.00 2.09% 584.67 2.33%

Performance Directorate 236.65 4.47% 161.87 2.99% 301.99 5.79% 277.01 5.17% 200.33 3.81% 186.43 3.66% 222.76 4.25% 209.99 4.12% 1,820.50 4.34%

Surgery & Cancer Division 874.34 3.29% 1026.23 3.72% 1093.61 4.07% 1108.29 4.01% 1257.34 4.54% 1056.45 3.93% 1223.77 4.40% 1121.00 4.16% 8,949.66 4.11%

Sep-18Aug-18May-18Apr-18 Jun-18 Jul-18 Oct-18 CumulativeNov-18

Workforce: SET Training - November (Month 8)CG & Directorate SET Training - November 2018 (Q3)


% Compliance

Doncaster & Bassetlaw Teaching Hospitals NHS FT 81.70%

Chief Executive Directorate 83.33%

Children & Families Division 83.86%

Clinical Specialist Division 85.38%

Directorate Of Strategy & Improvement 95.00%

Estates & Facilities 76.58%

Finance & Healthcare Contracting Directorate 96.07%

IT Information & Telecoms Directorate 90.60%

Medical Director Directorate 87.85%

Medicine Division 78.08%

Nursing Services Directorate 93.88%

People & Organisational Directorate 95.04%

Performance Directorate 80.07%

Surgery & Cancer Division 78.94%

SET Training

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


17/18 % Target - 90% Staff Suvey 2016 - 90%

Workforce: Appraisals - November (Month 8)CG & Directorate Appraisals - November (Q3)


Trust Total

AFC & M&D

% Completed

Doncaster & Bassetlaw Teaching Hospitals NHS FT 78.85

Chief Executive Directorate 100.00

Children & Families Division 79.34

Clinical Specialist Division 79.90

Directorate Of Strategy & Improvement 100.00

Estates & Facilities 94.07

Finance & Healthcare Contracting Directorate 98.61

IT Information & Telecoms Directorate 91.82

Medical Director Directorate 77.27

Medicine Division 72.72

Nursing Services Directorate 89.39

People & Organisational Directorate 95.40

Performance Directorate 79.48

Surgery & Cancer Division 70.63

Appraisal Reviews

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


17/18% Target - 90% Staff Survey 2016

Workforce: Staff in post -November (Month 8)

1

Title Staff Survey Action Plan – Progress Update

Report to Board of Directors Date 10/12/2018

Author Jayne Collingwood, Head of Leadership & OD

Karen Barnard, Director of People & OD


Decision

Assurance

Information


This paper provides the board with an update of progress made against the Trust staff survey action plan and the results of the most recent staff Friends and Family Test.

Staff recommendations as a place to have care or treatment has remained static at 76%. Staff recommendation as a place to work has shown a small negative change from 59% to 58% but the concern is the downward trend over the last 3 years from 2015‐16 when the response rate was mid to high 70s to Q2 now around the 58%.

In the most recent staff FFT Q2 18‐19 a very positive 85% of staff indicated they had had an appraisal within the appraisal season. Disappointingly only 22% of the respondents replied that it helped them to improve how they did their job.

A real good news story is that 84% of respondents stated that the organisation took positive action on health and well‐being. The access to high quality training and education was also a positive theme. There were many positive comments like the following “The service in Doncaster is great and staff are very friendly,” “Great place to work”.

In relation to questions around MSK and work related stress the picture was not so positive, quotes included, “Staff shortages put a lot of stress on members”.

“Every department seems to be short of staff and everyone I speak to including myself are very unhappy within the job due to stress etc. and morale is at an all‐time low”.

Within the narrative there were also references to the admin review and the length of time taken and quotes included “we are going through an admin review at moment and are unsure as to the future rolls of our jobs we have had very little information regarding this at the moment”.

There is an opportunity here to reflect upon the way we managed this change and consider what the lessons which can be learned from this.

2

There has been positive changes within the our general communications with the design of several newsletters and communications dedicated to celebrating achievements and sharing learning, such as ‘Sharing How We Care’, the ‘Medical Team’ bulletin and annualised version of ‘The Buzz’ have been well received as useful additions to our regular publications. Three has been a positive shift to ensure the publications strike a balance with the focus on patient care and finance in equal measure.

There has been work and investment into the redevelopment of the Trust’s intranet site, which will be launched by the beginning of 2019. There has been a significant increase in our social media presence through the adoption of Facebook, Twitter and the use of P&OD casts in the People & OD areas.

A poster template has been created for services, to support divisions to actively promote and display their Staff Survey results and taking positive actions to address them.

The newly re‐launched staff experience groups meetings are facilitated by the Leadership & OD team and supported by the communications team take place on all 3 hospital sites.

The creation of Richard Parker’s ‘Listening Events’, takes place across all sites every three months, as well as similar engagement groups and director drop‐in sessions. These are well received by staff but numbers of attendees remains lower than hoped. We will continue to advertise, promote and encourage attendance at all these events. In the divisions similar listening events have been mirrored by the leadership teams for their own staff groups.

This year’s DBTH full staff survey went live the first week in Wednesday 9th October and closed on Friday the 6th December. The results are embargoed until release date of February 2019.

The 2018 Trust staff survey results revealed variation in feedback from care groups, so each area designed their own action plan. It is important to acknowledge that the move to a divisional structure has challenged our ability to capture all the progress made against the original care group action plans. In specific areas we are able to cite examples of improvements delivered for example:

In Children’s and Families services a presentation has been displayed which in all areas in paediatric nursing and maternity which will cover aspects of the Flexible Working Policy. Data will also be provided for each are regarding how many flexible working agreements have been supported and how many have not been supported. A key element of the display included advice on who to approach if any members of staff feel their manager’s decision was unfair.

In Maternity services a matron's newsletter has been implemented. Staff engagement and listening events continue to happen at monthly intervals. Sharing of serious incident action plans in the clinical areas via regular team meetings and implement the use of safety huddles to embed changes in practice, feedback on DATIX and update knowledge locally on a daily basis continue to happen.

The student evaluation data (pre‐registration learners on placement) is predominantly positive and resulted in a number of those who trained with DBTH to go onto apply for substantive professional posts. This is a real positive endorsement of our organisation as a place to have care and to work.

Recognising the importance of the role of line managers the Board are also receiving a paper in respect of the Trust’s leadership development framework.

3


Key questions to consider in relation to the annual staff survey are:

Have we improved upon last year’s staff survey of result of 52%?

Has the adoption of a survey in paper format for staff in Estates and Facilities staff had a positive impact on response rates?

How do we ensure that the Trust captures and shares all the actions and good work happening in divisions to improve staff experience and engagement?

Key questions emerging from the FFT Q2 results are:

Why has the staff recommendations as a place to have care or treatment remained static at 76%?

Why has the recommendation as a place to work shown a downward trend over the last 3 years from 2015‐16 from 73% to 58%?

How do we help staff to appreciate and connect appraisal with helping them to do their job better?


People – As a Teaching Hospital we are committed to continuously developing the skills, innovation and leadership of our staff to provide high quality, efficient and effective care


Staff morale – the actions contained within the report look to provide assurance that the Trust is taking steps to improve staff morale.


Board members are asked to note this report.

The results from the full staff survey, which will be released in February 2019, will be compared to last year’s results and also triangulated with the Staff Friends and Family Test results.

To build and develop the staff experience network meetings and create a culture where two way dialogue is the way we do things around here.

WE CARE for our staff Each year our staff are invited to participate in the NHS Staff Survey, the largest survey of staff opinion in the UK. It gathers views on staff experience at work around key areas and includes: appraisal and development, health and well‐being, staff engagement and involvement and raising concerns. The survey adopts a method of assessing overall NHS performance on people management, which helps our organisation understand and compare our performance to other Acute Trusts.

For background and context the information in the table below reflects the high level staff survey results from 2018 which were reported last time and it remains unchanged.

Statement Acute Trust % DBTH %

Care of patients is my organisation’s top priority 76% 71%

I would recommend my organisation as a place to work 61% 51%

If friend or relative needed treatment I would be happy with the standard of care provided by this organisation –

71% 62%

Overall staff engagement score 3.79 3.66

The Trust’s overall staff engagement score remains static at 3.66 with the national average being 3.79. This figure is made up of the above score for staff recommending the Trust plus the scores for staff motivation at work (3.81) and staff ability to contribute towards improvements at work (65%).

Running in parallel with the annual staff survey there is a quarterly staff friends and family test survey. The table below reflects the comparative FFT scores with the addition of Quarter 1 and 2 data from 2018‐19.

COMPARATIVE SCORES – Staff FFT – At a glance 2015‐16 2016‐17 2017‐18 2018 ‐19

Time

Period

Q1 Q2 Q3

SS

Q4 Q1 Q2 Q3

SS

Q4 Q1 Q2 Q3

SS

Q4 Q1 Q2 Q3

SS

Q4

Care or

Treatment

80 78 64 72 76 73 59 80 76 76 62 79 76 76

Place to

work

73 77 60 66 60 58 48 79 59 59 51 76 59 58

It is interesting to note that recommendations as a place to have care or treatment has remained static at 76%. Recommendation as a place to work has shown a small negative change from 59% to 58% but the concern is the downward trend over the last 3 years from 2015‐16 when the response rate was mid to high 70s to Q2 now around the 58%.

2

For further information a more detailed breakdown on the Q2 FFT 2018‐19 results at organisational level is indicated below:

Question % response rate

Number of responses

In the last 12 months, have you had an appraisal, annual review, development review, or Knowledge and Skills Framework (KSF) development review?

85% 1438

If yes, did the review/appraisal help you improve how you do your job? 22% 1200

Does your organisation take positive action on health and well‐being? 84% 1394

In the last 12 months have you experienced MSK as a result of work activities?

73% 1407

During the last 12 months have you felt unwell as a result of work related stress?

59% 1407

It will please members to see that 85% of staff respondents had had an appraisal within the appraisal season. It is more disappointing that only 22% of the respondents replied that it helped them to improve how they did their job.

A real good news story is that 84% of respondents stated that the organisation took positive action on health and well‐being. The access to high quality training and education was also a positive theme. Many positive comments included like the following:

“The service in Doncaster is great and staff are very friendly,” “Great place to work”.

“Training and access to training is excellent and staff are well looked after”

“Doncaster and Bassetlaw Teaching Hospital has lots to offer. It has excellent learning

opportunities in many specialities. It has an excellent Education Department”.

In relation to questions around MSK and work related stress the picture was not so positive, quotes included:

“Staff shortages put a lot of stress on members”

“Every department seems to be short of staff and everyone I speak to including myself are very

unhappy within the job due to stress etc and morale is at an all‐time low”.

Within the narrative there were references to the admin review and the length of time taken and quotes included “we are going through an admin review at moment and are unsure as to the future rolls of our jobs we have had very little information regarding this at the moment”.

There is an opportunity here to reflect upon the way we managed this change and consider what the lessons which can be learned from this are.

From the 2018 full staff survey results a Trust level action plan was developed, a high level summary of progress to date is captured in the progress column added to the action plan appended to this paper.

3

The following narrative gives a more contextualised account of progress made against the Trust action plan:

Trust Level Communications The majority of our general communications continue be pushed through the Buzz, Trust Intranet/New Extranet, as well as staff Facebook group and Staff Brief. The design of several newsletters and communications dedicated to celebrating achievements and sharing learning, such as ‘Sharing How We Care’, the ‘Medical Team’ bulletin and annualised version of ‘The Buzz’ have been well received as useful additions to our regular publications. As recognised last time much of our communication regarding quality and performance was mainly directed towards clinical staff and there has been a positive shift to ensure the publications strike a balance with the focus on patient care and finance in equal measure.

There has been work and investment into the redevelopment of the Trust’s intranet site, which will be launched by the beginning of 2019. There has been a significant increase in our social media presence through the adoption of Facebook, Twitter and the use of P&OD casts in the People & OD areas.

A poster template has been created for services, to support divisions to actively promote and display their Staff Survey results and taking positive actions to address them.

The newly re‐launched staff experience groups meetings are facilitated by the Leadership & OD team and supported by the communications team take place on all 3 hospital sites. The first meetings were an open discussion on work related topics that staff considered important. Going forward to attract and grow attendance clear themes will be identified to give focus to the conversation and to identify actions for improvement.

The creation of Richard Parker’s ‘Listening Events’, takes place across all sites every three months, as well as similar engagement groups and director drop‐in sessions. These are well received by staff but numbers of attendees remains lower than hoped. We will continue to advertise, promote and encourage attendance at all these events. In the divisions similar listening events have been mirrored by the leadership teams for their own staff groups.

This year’s DBTH full staff survey went live the first week in Wednesday 9th October and closed on Friday the 6th December. The results are embargoed until release date of February 2019, after which an update paper will be presented to board.

Two key questions to consider will be:

Have we managed to achieve a higher response rate that last year’s survey of result of 52%?

Has the adoption of a survey in paper format for staff in Estates and Facilities staff had a positive impact on response rates from this staff group?

Local Action Plans The 2018 Trust staff survey results revealed variation in feedback from across the care groups, therefore the leadership teams were asked to develop their own SMART action plans. The action plans made it explicit how they would share their results and how they will continue to engage their teams in any progress made. It is important to acknowledge that the action plans were written when the care group structure was in place and we have subsequently moved to a divisional structure.

Whilst the action plans are still relevant and necessary we have experienced some challenge in pulling together and summarising all the progress made against the action plans.

The action plans needed to address key themes around:

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Flexible working

Opportunity for staff to undertake Qii projects/improvement team approach

Team communications

Visibility of leadership teams

Immediate line manager visibility and support

Health and wellbeing/pressure to come to work when unwell (presenteeism)

Survey response rates

Training plans/Appraisal training/CPD

Incident reporting/feedback from incidents and patient feedback

Conflict resolution/lone working

Recognition/celebrating achievements.

It is pleasing to report that lots of activity across Trust is happening in relation to the above themes. The following narrative is a headline summary of the work across the Trust that is happening in response to staff survey. It has been group together under key headings.

Staff Engagement and Communication In Children’s and Families services a presentation has been displayed which in all areas in paediatric nursing and maternity which will cover aspects of the Flexible Working Policy. Data will also be provided for each are regarding how many flexible working agreements have been supported and how many have not been supported. A key element of the display included advice on who to approach if any members of staff feel their manager’s decision was unfair.

In maternity services a matron's newsletter has been implemented. Staff engagement and listening events continue to happen at monthly intervals. Sharing of serious incident action plans in the clinical areas via regular team meetings and implement the use of safety huddles to embed changes in practice, feedback on DATIX and update knowledge locally on a daily basis continue to happen.

In emergency medicine the management team hosted an event to review experiences in each work area and obtain feedback on level of support and engagement for teams. A survey monkey was undertaken and feedback from staff has resulted in changes in team meeting structure, and to monthly and quarterly meetings undertaken in each area.

The P&OD team held a ‘strawberry wigwam’ engagement group which helped to shape the POD strategy, directorate infrastructure and prioritise educational investment for the team members.

The Senior Leadership team within P&OD regularly attend team meetings, conduct one to ones to ensure staff feel valued and have a direct line of communication and feel, able to influence things within their work areas. The Senior Leadership Team in operate an ‘open door’ policy to encourage an open communication with staff. Staff are actively encouraged to generate and share new creative ideas for Trust wide impact.

The TED team recently raised £850 through a bake sale in the education centre for Trust Charitable funds.

In 2019 TED are launching a Training and Education Network which primary purpose is staff engagement and networking and 3 dates have been planned for 2019/20. The impact and outputs from these events will inform their evolution.

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The student evaluation data (pre‐registration learners on placement) is predominantly positive and resulted in a number of those who trained with DBTH to go onto apply for substantive professional posts. This is a real positive endorsement of our organisation as a place to have care and to work.

Appraisal In emergency medicine Information was prepared and rolled out to areas via line managers regarding appraisal season. Additional training was rolled out across the care group and delivered within existing forums including team meetings, and management meetings. There was a concerted focus within the care group to implement better quality appraisals within the appraisal season this work has resulted in an increase in appraisal rates from 50.36% to 72.78% across the care group in July 2018.

Conflict Resolution In emergency medicine the care group lead worked with a Trust wide group with the aim of developing more effective conflict resolution training for staff in high risk areas including emergency department. The training is fit for purpose and targeted at staff in high risk areas. It is delivered in partnership with RDaSH and has been received well be staff in emergency department who are better equipped to respond to and de‐escalate situations.

Conclusion Board members should be assured that progress has been made against much of the approved corporate action plan. The paper around leadership development which is also being received at December’s Board of Directors should demonstrate the refreshed support which will be available to line managers during 2019. As detailed within the paper the move from Care Groups to Divisions does appear to have impacted on progress and focus on their local action plans.

Staff survey action plan 2018

Area of focus Actions Addressing staff survey question/ area

Success measure Progress

Overall staff experience/engagement programme.

Refresh the staff experience group and review the membership to ensure we have a cross section of staff groups and Care Group/Directorate representation.

Agree topics of discussions with the group and invite senior leaders to attend those discussions.

Response rate.

Recommendation as place to work and receive treatment.

Staff engagement score.

Improved response rate.

Improvement in recommendation of DBTH as place to work and to receive care.

Improvement in staff engagement score.

Mixed attendance at group; focused discussions around appraisal and the admin review time scales.

Following appointment of Head of Leadership & OD refreshed staff experience group advertised through Buzz and staff invited through targeted emails and open invitations. The Bassetlaw staff experience group took place on Tuesday 4th December.

Planned date for DRI staff experience group is 10th January 2019.

Roll‐out of Chief Executive Listening Events on a quarterly basis have been successful, however attendance has remained at around 10 people on average. Regardless, the quality of discussion is usually high and attendees enjoy the event.

While face‐to‐face engagement remains mixed due to time pressures and availability, engagement via social media has increased substantially, with P&OD colleagues using the Facebook to engage staff.

Review how we demonstrate the achievements of the Trust in relation to quality and performance and communicate to all staff. Regular celebration of our achievements.

Key finding 1: Staff recommending the Trust as a place to receive treatment and work (including whether staff believe patient care is a top priority for the Trust).

Improvement in key finding. Regular ‘achievement’ focused stories shared within the Buzz, as well as on the staff Facebook group. Also an increase of press releases related to these types of story which have appeared in local press, giving another avenue for staff to engage with Trust achievements.

Introduction of Sharing how we care conference and new bulletin launched to demonstrate positive messages.

Quality dashboard available to all areas.



Celebration of the success of the flu campaign and first Trust to achieve 75%.

Star Awards continue; monthly star awards publication within Buzz.

Opportunity for employee voice and involvement.

Introduce a formalised approach to the collation of staff feedback received during a specific period through the existing channels.

Timely analysis of the number of comments/ feedback and the tone (to act as a morale barometer, supplementing the Staff FFT work). This would provide the Board with an understanding of staff reaction to certain updates/changes.

Introduction of appraisal season giving staff the option for maintenance or developmental appraisals. Review of appraisal process for 2019/20 to incorporate greater reference to the Trust’s values.

Key finding 3: percentage of staff agreeing their role makes a difference to patients/ service users (6b).

Key finding 5: recognition and value of staff by organisation and managers (5a,5f,7g).

Key finding 6: Percentage of staff reporting good communication between senior management and staff (81‐d).

Improvements in scores in relevant key findings.

Reduced number of grievances.

Survey monkey used within some areas e.g. maternity. More to be done in terms of formalising this process. Some areas are easy to quantify when they become press releases or communication pieces, but work still to be done in regards to improvements in specific areas that are low key but none‐the‐less important.

Introduction of polls and survey using staff Facebook for health and wellbeing initiatives and other planned events to give greater voice to members of staff.

Introduced new structure charts to communicate management structure and further embedding of Chief Executive Listening Events. Also further offer to support senior managers to use staff engagement channels such as the Facebook group to communicate key messages and also be more visible within the organisation.

Appraisal season was introduced which resulted in an improved appraisal compliance rate and a programme management approach will be adopted for the lead up to appraisal season 19/20. This includes key messages and principles of quality appraisals. This will be linked with the new AfC framework for pay progression.

Demonstrate a clearer ‘you said’ ‘we did’ approach so employees see the value in having a voice and

Key finding 7: Percentage of staff able to contribute towards

Improvements in scores of relevant key findings.

Now Divisional structure is in place, work will begin to formalise a feedback structure and more ‘you said, we did’ type work. Currently, much of this is delivered informally via Trust communications and



provide shared learning about where that has been done well.

Responses to be formed based on insights gathered through champions and the staff experience group as well as all staff feedback (including the staff survey).

Develop case studies around staff survey improvements for Care Groups/ Corporate Directorates using the ‘you said we did’ approach. Care Group/Directorate action plans to be developed in conjunction with staff to ensure the priorities meet their needs.

Reference to Qii action plan to be included and Lean programme.

improvements at work (4a,4b,4d).

Key finding 3: percentage of staff agreeing their role makes a difference to patients/ service users (6b).

Improvements in morale measured through regular barometers.

Increase in service improvement projects led by front line services.

also on an adhoc basis using the staff Facebook group.

Successes have been seen in areas such as the T&O Qi project where clear actions are being put in place as a response to feedback. We are also being made more aware of other activities such as successful charitable bids and other items where feedback has resulted in a change – for example car parking permit extensions.

Communicating vision/strategy

Clearer representation/ visibility of executive team‐ especially within their senior teams communicating the ‘future’. Alignment of Executive Directors with Care Groups and sites.

Create a programme of engagement opportunities and engagement KPIs for the executive teams including presentation of staff brief, STAR awards presentations, back to the floor exercises and bespoke Q/A forum sessions with a wide ranging group of staff (such as CEO breakfast sessions with medics).





Following restructure into Divisions each Director/NED is aligned to a Care Group.

Thank you cards from the Chair acknowledging good work is appreciated.

Introduced further initiatives such as the P&ODCast, which will be rolled‐out further next year now Divisional structures are settled.

The STAR awards in September were a great success and will continue to be an annual event.

Regular listening events by Chief Executive including bespoke session for Consultant medical staff.

Regular interaction between Chief Executive and chair of TMC.



Deliver a series of staff engagement events (big health conversation/ let’s talk DBTH) supported by additional digital engagement.

Ensure senior staff/ line managers can support staff to make sense of their role within the context of the organisational strategy.

Key finding 7: Percentage of staff able to contribute towards improvements at work (4a,4b,4d).

Key finding 8: Staff satisfaction with level of responsibility and involvement (3a,3b,4c,5d,5e).

Key finding 3: percentage of staff agreeing that their role makes a difference to patients/ service users (6b).



Key finding 3: percentage of staff agreeing that their role makes a difference to patients/ service users (6b).

Number of contributions/ suggestions made by staff.

Chief Executive Listening events held on regular basis.

Within the Leadership programmes there is a focus on making the link between staff roles and contribution and our journey to become outstanding.

Conversations and discussions held on a daily basis on staff Facebook group about how we can make positive changes. There is also an increased ability to engage with issues quickly and resolve them before they grow into bigger concerns.

Refresh of leadership development programme on offer.

Develop a communications and engagement champions model, with key representatives from all Care Group/ Corporate Directorates committed to attendance at key events to hear and feedback (including staff brief, annual members meeting, transformation workshops).

Review the membership of the ‘staff experience group’ which will also include senior members of staff, staff side and governors.



Improvements to key findings.



Improved attendance at Staff Brief.

Continued increase in use of social media. Alternative

With the change to Divisions, the ‘champions’ model has not been achieved. However, with clearer communications and engagement channels such as newsletters, social media and the Intranet, this may no longer be necessary. General engagement has shifted to a wider approach rather than recruiting individuals to cascade messages (which has seen mixed results in the past). The goal now is to look to wider and more inclusive models and therefore recruiting ‘champions’ may be unnecessary.



Continue to deliver pro‐active communications campaigns making use of varied media.

means of communication identified through engagement with staff.

New approach taken in regards to staff experience group to broaden membership and facilitate further feedback sessions.

Communications expanded on to various social media platforms, with activity increasing month on month.

Supporting and engaging with managers.

Improve current intranet provision in order to provide line managers with all the key information, guidance and policies they need to manage staff enabling a self‐service approach.

Key finding 10: Support from immediate managers (5b, 7a‐e).

Improvement in key findings.

Key finding 10: Support from immediate managers (5b, 7a‐e).

Measure use of intranet site.

The VIVUP Portal / Intranet sites are easy to navigate, well maintained with up to date information for staff to use as a resource to support their health and well‐being. Ongoing review of material on the portal is ensured through the health champions group.

New intranet/extranet due to go live in January 2019. Involvement of Care Groups/directorates in reviewing the future content.

Develop a line manager bulletin/ blog/ portal to include support and guidance on key people issues. Contents could include:

Steps to delivering quality appraisals including key messages to staff (video of a good appraisal)

Effective team working

The importance of supporting health and wellbeing of staff with particular focus on mental wellbeing and resilience (links to CQUIN for 2017/18

Sickness absence management best practice.

Key Finding 9. Effective team working (4h‐j).

Key finding 10: Support from immediate managers.

Key finding 11: Percentage of staff appraised in the last 12 months (20a).

Key finding 12: Quality of appraisals (20b‐d).

Key finding 13: Quality of non‐

Improvements in key findings.

Reduced sickness absence rates.

Improved appraisal rates.

Reduced grievances.

The ‘Sharing How We Care’ Conference was a success and will be repeated again in April 2019. This was an opportunity to showcase best practice around improving our patient and staff experiences whilst ensuring a consistent theme of the WE CARE values.

Short films of quality appraisals were adopted and landed well with our teams. In March of 2018, the health and wellbeing flower was re‐designed to include the text “Health and Wellbeing” alongside the flower logo to make it easier for staff members to recognise H&WB related initiatives.

The VIVUP portal has been expanded since its launch 14 months ago. The portal now includes salary sacrifice, Help EAP, Credit Union, Cycle to work along with advice and support on many health and wellbeing related subjects including Stress, Sleep and Menopause Advice. The Health and Wellbeing Team have taken every opportunity



mandatory training, learning or development (18b‐d).

Key Finding 19: Organisation and management interest in and action on health and wellbeing (7f, 9a).

to raise awareness of the Vivup portal resulting in the number of registrations rising from 805 to 1356. This is a 68.4% uplift in the last 10 months.

A Health and Wellbeing Champions Facebook group was set up to increase avenues of communication. There are 55 health and wellbeing champions throughout the Trust and we continue to source training for the champions in their area of interest including drug and alcohol awareness and domestic violence. The Nottinghamshire Wellbeing @ Work Gold Award was achieved in 2017 and the Platinum portfolio was submitted recently.

Over the last 12 months, Neyber financial support services and free bike doctor services have been introduced to staff. We have initiated bi‐annual Health and wellbeing Fairs to showcase the Trusts H&WB offer to all staff which were all well attended. We aim to double the number of stands at the next fair.

The Health and Wellbeing Committee continues to meet bi‐monthly to discuss progress. Decisions are made with regards to staff lottery bids, the criteria has an emphasis on improving staffs health and wellbeing. The most recent bids have included funding for a 6 week yoga course at Mexborough Montagu, running vests for staff to borrow when partaking in sporting events and raising money for the DBTH charity, netball kit for the DBTH team and benches to enable a department to eat lunch together and increase staff morale.

Weekly H&WB updates are published in Buzz, promoting positive health messages, initiatives, campaigns and potential offers.



Going forward into 2019: lunchtime meditation sessions, yoga at MMH and onsite smoking session will all start January.

Adopt a line manager first approach for all communications involving significant change. This will enable managers to understand the reasons for change and to feel equipped to support their staff and help them to make sense of their roles in the change.

Ensure all Care Groups and Directorates understand and share staff survey feedback – engaging with staff to understand the results and develop actions to address areas for concern in their survey results.

Explore with the senior leadership team across the Trust how best to communicate with them.




Line managers questionnaire as part of the launch of the bulletin/blog/portal.

Staff survey engagement events taken place in Care Groups.

The TED and P&OD staff proactively support communication around organisational change. Staff are located in all sites and areas of our business and well placed to share and cascade information.

Also working into HEIs, FEIs, HEE and SY education networks and the place based activity.

All Care Groups and directorates developed action plans to address the top 3 issues. Engagement with staff undertaken in order to identify these priority areas.

Also encouraged managers to cascade important messages to members of staff, as well as included an offer to set up department/service private social media groups.

Develop a leadership strategy and programme for the organisation to include talent management and succession planning.



Strategy in place and programmes identified.

A Leadership Development and Organisational Development framework has been presented to the executives and Management Board for consideration. Paper to Board of Directors in December 2018. Board development programme in place. Regular attendance by NEDs across the Trust.

Review DBTH management programme to ensure managers are equipped to manage people issues appropriately with specific reference on team working and resilience.



Positive evaluation of programme.

A new series of Leadership development programmes have been written to strengthen the leadership development offer. A strong focus is building a resilient team.

Management skills passport is oversubscribed.



Key finding 9: Effective team working.

Visual campaign to ensure that everyone working, visiting or receiving treatment within the Trust is aware of acceptable behaviours towards members of Team DBTH.

Key findings 22 & 23: Percentage of staff experiencing violence.

Reduced incidence of violence.

Living the WE CARE values is an under pinning theme in all leadership development programmes. It will also be offered as a stand‐alone Sound Bite for leaders and teams.

Regular reminders to all staff on the importance of reporting incidents of violence, harassment, bullying or abuse. Promote wider circulation of Risky Business to non‐clinical staff.

Key findings 24 & 27: Percentage of staff reporting most recent experience of violence, harassment, bullying or abuse.

Improvement in reporting of incidents.

The P&OD team actively contribute to the content of the ‘Sharing how we Care’ newsletter.

There remains work to do to ensure wider cascade of Health and Safety issues across the teams.

Campaign to reinforce the Trust’s values; inclusion of the Trust’s values and behaviours in appraisal process for 2019/20.

Key finding 1: Staff recommending the Trust as a place to work and receive treatment.


Reduced vacancy rates.

Improved retention and turnover figures.

The WE CARE values are embedded in the appraisal training for leaders and staff.

Develop work plans from the We Care for our Junior Doctors Forum and the Specialty and Associate Specialist Doctor Forum. To be monitored via WEC and JLNC.

Key finding 26: Percentage of staff experiencing bullying, harassment or abuse from staff.

Improvement in key findings. A report went to WEC September 2018 showing key work streams and achievements so far in accommodation.

Title Workforce update

Report to Board of Directors Date December 2018

Author Karen Barnard, Director of People & OD


Decision

Assurance x

Information

Executive summary containing key messages and issues This report provides the Board of Directors with the current position of key vacancies. There is an overall vacancy rate of 6.9% across the Trust with nursing and midwifery at 4.6%, allied health professions/scientific & professions at 4% and medical staff at 13.8%. Benchmarking data is also provided from the model hospital portal with regard to vacancy levels. This paper provides an update from the July report on medical staff vacancies and the current plans for international recruitment. In addition the report provides an update on nursing vacancies, the ongoing discussions with HEIs and the cohort of Trainee Nurse Associates who commence their training this month. An update is also provided on other areas within the Trust including those where there is high agency spend. The recent re-commencement of the medical grip and control meetings will enable improved monitoring of how vacancies are being filled and whether further discussions are required regarding models of service delivery.

Key questions posed by the report Is the Board assured of the work underway to recruit to our vacancies and to retain and develop our existing workforce?

How this report contributes to the delivery of the strategic objectives People – As a Teaching Hospital we are committed to continuously developing the skills, innovation and leadership of our staff to provide high quality, efficient and effective care

How this report impacts on current risks or highlights new risks The update provided in this report provides details of how the Trust is looking to reduce vacancy levels and agency spend and to recruit the right staff with the right skills and values.


The Board is asked to confirm that the Board is assured by the work being undertaken by the Trust to reduce vacancy levels, reduce agency expenditure and improve the turnover and retention rates and that appropriate monitoring is in place.

2

Workforce report December 2018

The model hospital portal now provides benchmarking data in respect of vacancies for some staff groups.

It is possible to use various peer groups. The table below is based on September 2018 data and is taken

from the monthly returns submitted by Trusts.

DBTH SY&B ICS NHSI sub region

NHSI Region

National

Total vacancy 5.7% 5.7% 5.85% 6.18% 9.26%

Medical & Dental

9.82% 10.43% 9.82% 9.02% 9.02%

Registered nurses

6.64% 9.6% 10.65% 10% 12.05%

Unregistered nurses

2.16% 8.54% 7.91% 6.5% 8.76%

Non-medical, non-clinical

8.2%* 4.69% 4.82% 6.91% 8.05%

*this grouping is assumed to be admin, estates and ancillary - members of the Board will recall that we

have been holding admin vacancies whilst the clinical admin review is completed.

Across the Trust we have a budgeted establishment of 5880wte in month 7; this figure is broken down

into the following staff groups:

Qualified nursing: 1752wte

Nursing support: 903wte

Medical and dental: 672wte

Admin and Clerical: 1024wte

Allied Health Professions/Scientific & Professional: 858wte

Estates and ancillary: 552wte

From month 7 data we have the following vacancies identified by comparing the number of staff currently

employed (contracted wte) with budgeted establishment:

Qualified nursing & midwifery: 82wte (4.6%)

Nursing support: 27wte (3.2%)

Medical and dental: 93wte (13.8%)

Admin and Clerical: 69wte (6.73%)

Allied Health Professions/Scientific & Professional: 35wte (4%)

Estates and ancillary: 69wte (12.5%)

Overall the Trust vacancy rate at month 7 was 6.9% (406 wte vacancies) against a target of 5%, however

when temporary resource is included (overtime, bank and agency) this is reduced to 2.3% (135wte

vacancies), although this does vary by staff group. The variation in the data between the 2 sources is

associated with our hosting or otherwise of doctors in training. During month 7 we utilised the equivalent

of 58wte agency medical staff, 51wte other staff groups including nursing staff, 126wte bank nursing

support and 53wte bank qualified nurses and midwives. Whilst bank and agency staff is used to cover

vacancies we also have 123wte staff on maternity leave. Only 30% of medical agency spend is related to

Consultant posts.

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Medical and dental

Whilst the overall vacancy rate is 13.8% (93wte) this is made up as follows:

Deanery posts – the Trust is allocated doctors into trainee posts – we currently have 32.9wte vacancies –

below demonstrates the varying deanery fill rates across the specialties.

Recent indications are that the Trust receives a proportionate allocation of trainee doctors – the deanery

is due to provide analysis of fill rates across Yorkshire & Humber. The key attention to improving fill rates

is to ensure that the Trust is seen as a positive experience for training. The GMC survey has demonstrated

an improving picture in the majority of specialties – an update on the action plan is being received by QEC

this month; particular attention is given to doctors in training through the We Care for our Junior Doctors

forum and the Safe Working Forum. In addition to these deanery posts the Trust also employs Trust

doctors who work alongside doctors in rotation posts.

Consultant medical staff: 27wte – Ophthalmology, Renal, COTE, Respiratory, Diabetes & Endocrinology,

Gastroenterology, Acute Medicine, Anaesthetics and Histopathology. Following discussions with Divisional

Directors we are exploring international recruitment for Gastroenterology, Anaesthetics and

Rheumatology. With regard to Histopathology recent recruitment has not been successful and therefore

discussions are taking place within the ICS regarding joint appointments. Since the last report in July 2018

the Trust has successfully recruited to posts in Stroke, Orthopaedics, Obstetrics/Gynaecology, and

Ophthalmology.

The largest proportion of gaps is specialty doctors, the bulk of which are in the Emergency Department

and Anaesthesia. A business case is being developed to undertake international recruitment – the Clinical

Reference Group within the ICS have agreed to support some funding for Trusts to undertake this

recruitment. In addition, as the Board will recall, we have entered into a partnership with Nepal to provide

a training programme which will see 8 specialty doctors spend 2 years within the Trust – the first 4 doctors

have commenced in Nepal and will join us in October 2019.

The medical grip and control meetings have re-commenced to ensure that bank and agency cover is being

used appropriately and to monitor progress in filling vacancies.

Nursing and midwifery

As described above the Trust has a lower vacancy rate than many Trusts. The specialties of most concern

are theatres and paediatrics. As members will be aware the recent CQC inspection has highlighted the

need to increase our paediatric nurse staffing further. Discussions have also taken place with Sheffield

Hallam University and University of Sheffield regarding the paediatric modules available for adult nurses.

VACANCIES January February March April May June July August September October

Medicine 3 3 4 5 5 5 5 6 9 8

Anaesthetics 2 1 1 2 1 1 1 3.7 3.2 3.7

Emergency medicine 6 5 5 5 5 5 5 1 1.4 5.4

Obstetrics & Gynaecology 7 8 8 10 10 10 10 12.4 12.4 10.6

Paediatrics 1 6 6 8 7 7 7 1.9 1.4 2

GU Medicine 0 1 1 0 0 0 0 0 0 0

Elderly Medicine 1 1 1 1 1 1 1 1.2 0.2 0.2

Radiology 2 2 1 0 0 0 0 0 0 0

General Surgery 1 0 0 5 5 6 6 1.5 1.5 2

Trauma & Orthopaedics 1 1 1 1 1 1 1 1 0 0

ENT 0 0 0 0 0 0 0 1 0 0

ICT 1 1 1 1 1 1

Total 25 29 29 37 35 36 36 30.7 30.1 32.9

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The recent application process for newly qualified nurses has resulted in 38 applications for adult nurse

roles and 8 for children’s nurse roles – a total of 18 who are due to qualify in March 2019 – 13 have been

offered roles; the total included applications from already qualified nurses and students due to qualify in

September 2019 – all these are being managed appropriately and have resulted in 4 Paediatric nurses

being offered posts who will be commencing shortly. In addition we have had approaches from paediatric

nurses wishing to return to DBTH. 19 trainee nurse associates have been recruited and commence this

month. We originally appointed 15 and were then asked if we could increase our intake which we have

done – we understand we are the only Trust to have been able to achieve this in the timescale. In

addition 24 Assistant Practitioners have recently qualified with a further 2 due to qualify shortly – this was

our first cohort of trainee APs.

A business case for a further cohort of trainee Assistant Practitioners is being finalised which will address

some of the shortfall in theatres. With regard to children’s nurses the Trust is in discussion with Sheffield

Hallam University to scope us taking a larger cohort of students on placement who would undertake the

majority of their placements within Doncaster. Following the success of third year students being on

placement from Lincoln University and them all remaining with us post qualifying we are discussing taking

students earlier in their training together with discussions with Derby University. In addition we are

exploring nurse apprenticeships with Sunderland University and the Open University. Following the

partnership with Nepal in respect of emergency medical staff the Trust is also exploring an approach to

recruit 10 nurses each year. We also understand that HEE is continuing with its programme ‘earn, learn,

return’; therefore we will explore the options we might be able to access through this programme.

The Trust runs a training scheme for HCAs in conjunction with NHS Professionals. Through this scheme

HCAs work 30 hours a week on specific wards for 6 months. We currently have 20 working across the

Trust. The Trust regularly runs assessment centres for HCAs. There are currently 17 candidates undergoing

pre-employment checks.

Retention

As important as recruitment is a focus on retaining our workforce – as reported last month as an ICS we

have elected to join cohort 4 of NHSI’s retention programme. This cohort has particular focus on nurses

and midwives. We are required to develop an action plan by March 2019. At the launch event we heard

from Trusts in previous cohorts and anticipate that our action plan will focus on preceptorship,

introducing a transfer scheme across the Trust, flexible working and line management support. We are

undertaking a detailed analysis of the nursing and midwifery workforce to determine where the highest

levels of turnover are i.e. is it newly qualified staff, new starters to the Trust, or staff able to access their

pension. This will inform our priorities for the action plan. This piece of work will report in to the

Workforce, Education and Research committee with updates to the Quality and Effectiveness Committee.

Pharmacy

There is a particular problem with band 7 pharmacists which is longstanding and is due to problems with

both recruitment and retention. While this is in part a national issue (insufficient numbers) there are also

some local components. The main factors are:

The DBTH rota is seen as particularly onerous.

The big tertiary centres (particularly Sheffield and Leeds in our case) can offer less onerous working patterns and more specialist roles (which are seen as good career moves).

Lack of access to places for non-medical prescribing courses.

5

National initiatives (such as placing clinical pharmacists in GP practices and nursing homes) are a draw on this grade, offering early career progression while not contribution to training (the majority of which takes place in acute hospitals)

We have taken action to address this in a number of ways. Through skill mix we have reduced our

reliance on band 7 pharmacists (increasing the number of band 6, which we can recruit) and have

improved the quality of the rota by reducing evening and weekend commitments from 1 in 4 to 1 in 6 and

safeguarding the specialist experience that is valued. In addition our ‘grow your own’ approach by

introducing pass-through from band 6 to band 7 is starting to bear fruit. We have however been able to

recruit recently and have two new pharmacists joining us in this month and March. We expect to fill all

the other pharmacist vacancies by the summer and that the skill mix and rota changes will mean we have

far more stability from then on.

Imaging

We currently have a high reliance on agency locums within Imaging with around 20 vacancies. The division

is introducing a support role which will reduce this agency requirement through a change in the skill mix

of the team and provide additional training opportunities for existing radiographers.

Estates and Facilities

Within Estates we experience difficulty in recruiting to electrician roles – the Director of Estates &

Facilities and Director of Education are working with the Doncaster University Technical College in

anticipation of improvements within technical professions. Service Assistants have traditionally provided a

source of recruitment to healthcare support worker roles (this may change following the planned

transition of all Band 1 roles to Band 2) and therefore tend to have a higher turnover rate. The

recruitment team is undertaking a review of the assessment centre approach for this staff group to

explore how the recruitment process might be accelerated. A recruitment tracking system is being

introduced in order that the team and managers can monitor and manage the recruitment process more

easily.

Administrative and clerical staff

The recruitment process following the clinical admin review is almost complete with vacant Band 2 and

apprenticeship posts now being advertised. Staff in fixed term posts associated with this review have now

been made permanent. The process is being achieved without any redundancies and has offered a

number of promotion opportunities. We therefore anticipate a significant reduction in vacant posts in the

coming months.

Conclusions

Overall the Trust benchmarks favourably against other Trusts; however we recognise that our agency

spend, in particular for medical staff, is greater than many Trusts. This is in particular driven by our

specialty doctor gaps (middle tier). A deep dive on agency spend was recently presented to the Finance

and Performance committee detailing the information available to Divisions, the reasons associated with

the spend and the monitoring process being reinstated through weekly grip and control meetings.

International recruitment is being pursued where appropriate but just as important is the focus on how

we retain staff at all stages of their career.

6

Recommendations

Following the re-commencement of the weekly medical grip and control meetings a weekly log of vacant

posts will be produced and progress in filling these vacancies will be monitored at that meeting. This data

will then be collated on a monthly basis and added to the monthly reports into the Finance and

Performance Committee. With the re-introduction of Divisional accountability meetings Division and

Directorate leadership teams will be held accountable for progress against improved staffing levels and

consideration of changes to staffing models. Through the business planning process taking place early

2019 workforce plans will be developed by Divisions and Directorates with the support of colleagues

across the People & OD team. The establishment of an operational workforce group reporting to the

Workforce, Education & Research committee will facilitate monitoring of these workforce plans in relation

to the introduction of new/revised roles across the Trust and discussions with FEIs and HEIs. Assurance

will be provided through reports into the Quality & Effectiveness Committee. Agency spend against

targets will continue to be monitored through reports to Finance & Performance Committee. Progress

against the retention action plan will be monitored by the Workforce, Education & Research Committee

reporting into QEC.

Title Leadership and Organisational Development Framework

Report to Board of Directors Date December 2018

Author Jayne Collingwood, Head of Leadership & OD

Karen Barnard, Director of People & OD


Decision

Assurance

Information


This Leadership and Organisational Development framework has been developed to support Doncaster and Bassetlaw Teaching Hospital Trust’s vision to be the Safest Trust in England and ‘Outstanding’ in all we do. It has been developed through conversations with many leaders across the Trust and has been considered by the Executive Team and Management Board.

In developing the leadership and organisational (OD) framework it is recognised;

That the best way to influence is to set an example through positive role modelling

That good leadership is critical to delivering change and improvement

That communication and engagement at all levels is an essential ingredient to success

That leaders set the tone and climate of an organisation

An open and honest culture facilitates learning and growth.

It is incumbent upon DBTH to:

Recruit, develop and retain the best staff

Embed the ‘We Care’ values in everything we do

Role model our values and behaviours as ‘the way we do things around here’

Challenge and hold people to account when not modelling our values and behaviours

Create and build a culture of trust amongst our staff.

Key components of the framework are:

Develop our Leaders There will be a range of leadership development programmes for staff at various levels within DBTH ranging from the Shadow Board, leadership and management apprenticeships and access to programmes run by the Leadership Academy. Quality Improvement (QI) will be a strong focus of the Leadership development programmes and will involve collaboration with the QI team, People Business Partners and Training and Education Development functions.

Organisational Development To create a culture where our ‘We Care’ values are lived and embedded and it is ‘the way we do things around here’ we will adopt a structured approach to Organisational Development (OD). All requests for interventions will be managed through the phases of the OD cycle through a structured methodology which covers entry and contracting phase, diagnostic phase, intervention and evaluation phase and close down. This will help to ensure that the appropriate OD intervention is applied and there is a clear outcome and end point to the work.

Value our People Strong leadership and engagement can and does encourage team cohesion, a sense of team optimism about work and builds a sense of efficacy. It enables team members to feel confident in the ability of the team to achieve its goals and deliver high quality, compassionate and inspiring care. Good leaders create a positive climate for staff so that they feel valued and that they experience a sense of belonging to an organisation and a connection with the core business purpose. If staff feel engaged they have the emotional capacity to care for others much better.


Is the Board assured that the Leadership and OD framework will provide appropriate support and development to the leadership community within the Trust enabling our staff to have a positive experience working within DBTH.


People – As a Teaching Hospital we are committed to continuously developing the skills, innovation and leadership of our staff to provide high quality, efficient and effective care

This framework contributes to the strategic development of our people and to the Well‐Led requirements of the CQC.


Staff morale – this Leadership and OD framework will support the development of our leadership community and ensure that members of Team DBTH are appropriately supported enabling them to have a positive experience of working at the Trust.


The Board of Directors is asked to approve this Leadership & OD framework. A prospectus is being finalised for the programmes for 2019.

1 V.1 03/12/18 Leadership & OD Team

Leadership & Organisational

Development Framework


1.0 Context

At Doncaster and Bassetlaw Teaching Hospital Trust we have a vision to be the Safest Trust in

England and ‘Outstanding’ in all we do.

Our vision is underpinned by our ‘We Care’ values;

We always put the patient first.

Everyone counts – we treat each other with courtesy, honest, respect and dignity.

Committed to quality and continuously improving patient experience.

Always caring and compassionate.

Responsible and accountable for our actions – taking pride in our work.

Encouraging and valuing our diverse staff and rewarding ability and innovation.


Our Strategic Objectives are represented below;

We employ a large number of people within diverse roles, our workforce composition is reflected in

the table below;

Staff Group Headcount FTE

Add Prof Scientific and Technic 188 171.29

Additional Clinical Services 1,420 1,176.65

Administrative and Clerical 1,263 1,037.51

Allied Health Professionals 374 322.31

Estates and Ancillary 675 472.53

Healthcare Scientists 139 122.72

Medical and Dental 576 494.69

Nursing and Midwifery Registered 1,863 1,596.11

Grand Total 6,498 5,393.80

As an organisation we recognise that often the ‘here and now’ pressures on leaders leaves them

little time to reflect on their leadership and how best to lead change. This framework has been

developed to support our leaders to lead effectively whilst delivering the changes we need to realise

our vision. In developing our leadership and organisational (OD) framework we recognise;

That the best way to influence is to set an example through positive role modelling

That good leadership is critical to delivering change and improvement

That communication and engagement at all levels is an essential ingredient to success

That leaders set the tone and climate of an organisation

An open and honest culture facilitates learning and growth.


It is our ambition to:

Recruit, develop and retain the best staff

Embed the We Care Values in everything we do

Role model our values and behaviours as ‘the way we do things around here’

Challenge and hold people to account when not modelling our values and behaviours

Create and build a culture of trust amongst our staff

Develop a committed workforce who are bought into our vision and our priorities with a

strong focus on delivering quality care for our patients

Develop effective, competent well trained leaders at every level

Move from this is how we have always done things towards a ‘how can we improve?’ based

upon a culture of continuous improvement

Actively engage with our service users and their families to ensure all their interactions and

experiences within our hospitals are positive.

Build a reputation as ‘Outstanding’ in all we do.

2.0 Our Framework

At DBTH we recognise that our leaders are critical to our journey to be the Safest Trust in England.

We want all our leaders at all levels with both formal and informal kinds of authority, direct and

indirect leadership, clinical and non‐clinical roles to model our values and behaviours in everything

they do. We want to support and develop them to lead services, lead people, lead change and strive

to continuously improve.


The Leadership and Organisational Development strategic framework is captured in the in the

diagram below:

*National Leadership Development Drivers

It is important to acknowledge the national leadership development framework ‘Developing People

– Improving Care: (December 2016) which is a call to action on skill‐building in improvement,

leadership development and talent management at local and regional levels.

Four critical capabilities that we need to develop in our leaders within the DBTH are;

● Systems leadership ‐ These skills help leaders to build trusting relationships, agree shared system

goals and collaborate across and beyond organisational and professional boundaries. This work

requires a different mind‐set and a different way of working our leaders need to think system rather

than organisation, think big picture as opposed to small picture, operate with courage and bravery.

•Leadership Development* DEVELOP

•BELONG

•THRIVE

•HEAR ‐Masterclass

•Apprenticeships

• Sound Bites

•Qi Training

•Organsational Development Interventions

•Psychometric Instruments

•Talent Management

•Team Development

•Team Interventions

•Coaching Capacity and Capability

•Coaching Service

•Coaching Supervision

•Access to coaching

•QI Coaching

•Mentoring

•Inclusive leadership

•Equality and Diversity and Inclusion

•Equality standards including WRES, DES

•Staff survey and FFT

•Staff engagement**

•Staff experience

Value our

People

Create a Coaching Culture

Develop our

Leaders

Support our

Teams


● Improvement skills for staff at all levels ‐ Service improvement is integral to leadership

development and ‘the way we do things around here’ as established methods will drive

improvement in operational performance, staff satisfaction and quality.

● Compassionate, inclusive leadership ‐ Means paying close attention to all the people you lead,

understanding the situations they face, responding empathetically and taking thoughtful and

appropriate action to help. Inclusive leadership means progressing equality, valuing diversity and

challenging power imbalances to create just learning cultures and great places to work.

●Talent Management – To address current vacancies and future leadership pipelines with the right

numbers of diverse, appropriately developed people, we need to have robust plans and approaches

to nurturing our talent and growing our leaders of the future.

**Staff Engagement

The NHS Employers staff engagement star closely aligns with the ‘Value our People’ section of this

framework . The five point staff engagement star shown below reflects how each of the elements

collectively contribute to an organisations overall commitment to staff engagement. The star

demonstrates the different parts of the system that we will ensure happen to support effective staff

engagement.

7 Final 14/12/18

2.1 Create a Coaching Culture

Coaching is a powerful leadership tool whose efficacy goes beyond the boundaries of culture, discipline and personality. A coaching style of leadership can

impact on an individual’s performance and can be truly transformational. Helping people to realise their full potential will have a significant impact upon

organisational performance and outcomes. To create a coaching culture we need to ensure our leaders have the knowledge and capability to apply a

coaching style to their leadership practice.

DBTH has already made a significant investment in terms of developing a cohort of trained coaches. We currently have 19 trained coaches within the

organisation. There are challenges around ensuring coaches are allowed time to coach and also ensuring the quality of their coaching practice through

regular coaching supervision. Culturally we have work to do to educate managers and leaders in the art and practice of coaching as a leadership style and

the associated benefits.

The table below represents our approach to building and developing our coaching capacity and capability:

Coaching About the programme Who it is for Time Commitment Costs £ Attendees

Numbers

Additional Notes

Coaching

Capability

Train leaders in adopting a

coaching leadership style

All leaders and

managers

Sound Bites – 90

minutes

Included in

leadership

development

programmes

0 20 Incorporate into development

programmes and as stand‐alone

Sound Bite.

8 Final 14/12/18

Coaching About the programme Who it is for Time Commitment Costs £ Attendees

Numbers

Additional Notes

Increase

coaching

capacity

Develop more coaches within

DBTH to support workforce

development

New coaches tbc 0 8 Seek access to centrally funded

coach development through

Leadership Academy funded

programmes.

Increase

access to

external

coaches

Facilitate appropriate access

to external coaches for senior

leaders

Senior Leaders

(8b above)

tbc tbc 6 Agree model to facilitate access

to approved external coaches for

Senior Leaders.

Mentoring for Doctors

At DBTH we have an aspiration to increase access to mentors for our medical work force. We recognise that having a mentor can help work performance,

motivation and engagement, as well as clarification of personal and professional career goals. Mentoring is usually based on a process of support,

questioning and listening. For the mentee it provides a safe haven to explore professional development and work‐based issues. The mentor provides a

sounding board for difficult decisions, an independent view on things, access to knowledge and experience and someone to encourage you when things are

not going well. Mentees typically progress faster in their learning than those without a mentor. For the mentor it is a great opportunity to develop skills in

developing others and often leads to invaluable insights into their own working situation and satisfaction from helping another grow and develop.

We will offer a short development programme for Consultants who would made ideal mentors for new consultants and more junior colleagues.

9 Final 14/12/18

Mentoring About the programme Who it is for Time Commitment Costs £ Attendees

Numbers

Additional Notes

Train medical colleagues in

mentor skills

Doctors willing

to act as a

mentor to

others

½ day development

programme

Time 16 New mentor programme

2.2 Leadership Development

We will create, promote and deliver a range of leadership development programmes for staff at various levels within DBTH. We will design a prospectus to

advertise the leadership development opportunities so these can be discussed within the appraisal framework. The emergent development needs from

appraisal conversations will also inform our future capacity and delivery plans.

Quality Improvement (QI) is a strong focus of the Leadership development programmes and we will collaborate with the QI team, People Business Partners

and Training and Education Development functions to ensure;

Consistent language, messages and themes

Golden threads of continuous quality improvement will run through all the development programmes

Mutual support and collaborative working is central to how we do things

The right intervention is delivered, to the right people, at the right time, by the right team.

The QI training will:

Clarify how Quality Improvement fits within the leadership role

Introduce core Improvement Methods concepts of value, waste and zero defects

Inspire participants to view their work area through a different lens

10 Final 14/12/18

Explain how to adopt QI tools and techniques into every day practice.

The table below reflects the leadership development programmes that will be available for staff to access:

Name of

Programme

About the programme Who it is for Time

Commitment

Costs £ Attendees

Numbers

Programme

Preceptorship A period of supported practice

for newly qualified registered

practitioners. It enables them to

build confidence and further

develop their skills.

Band 5 Nurses,

AHPs, ODPs

12 day

programme

Duration: One

year

Internal

Delivery

40 1 day within the programme

focused on ‘Everyday Leadership’

DEVELOP For new managers/leaders at

the beginning of their

management career or

managers with little or no

managerial experience. It will

develop participants’ leadership

and management knowledge

and skills to enable them to lead

with confidence.

For staff new

to a

management

and leadership

role with line

management

responsibility

for others

4 days

(one day per

month)

Internal

Delivery

40 *Replaces 6 day Management

Skills Passport.

Includes Recruitment, Appraisal,

sickness absence, discipline and

Grievance, Building and Leading a

Team.

Includes one hour QI Component

Model for improvement / PDSA,

What is Qi, Measurement ,

Toolkit , 6S

11 Final 14/12/18

Name of

Programme


Commitment

Costs £ Attendees

Numbers

Programme

BELONG Middle leaders programme

Provides participants with the

opportunity to explore self and

how they lead.

Non‐clinical

leaders,

Nurses,

Midwives,

Allied

Healthcare

Professions

Band 6 and 7

2 days plus ½

day

Internal

Delivery

£40 + Vat pp

for Discovery

Insights

Report

40 New Programme

Includes Insights Report, leader

as a Coach and ½ day QI which

covers Measurement, Tools,

Change management, Readiness

to change, UDDS, 6S, purpose

road, nudge, lean.

THRIVE Senior Leaders Programme (8a

and above) which facilitates

reflection on own leadership

strengths and areas for

development. Effective

leadership, system leadership

and compassionate leadership

and Talent management

Non‐clinical

Leaders,

Nurses,

Midwives,

Allied

Healthcare

Professions

2 days Internal

Delivery

£40 + Vat pp

for HCLM 360

feedback

report

20 New Programme

Includes Healthcare Leadership

Model 360 report, Inclusive

Leadership and Compassionate

Leadership

Qi Silver and champions (1 day)

Measurement, Tools, Change

management, Readiness to

change, UDDS, 6S, purpose road,

nudge, lean. My role, My project.

Celebrate success and share.

12 Final 14/12/18

Name of

Programme


Commitment

Costs £ Attendees

Numbers

Programme

HEAR

Master class

Series

Masterclass series will include

high profile leaders/experts to

share their knowledge and

experience on relevant topics

Divisional

Teams

2 hours –

Quarterly

Dependent

upon cost of

speaker

40 New Programme

Plan to utilise existing networks

and speakers for free where

possible

Shadow

Board

Programme

This programme aims to expose

the next line of senior leaders to

the role and functions of the

board

Aspirant

Directors,

Assistant

Directors,

Divisional

Directors,

Heads of Dept.

6 days in total £15,000 plus

VAT

15 Seeking resource from Leadership

Academy to support this

programme

FMLM 360 Promote an opportunity for a

Faculty of Medical Leadership

and Management 360 feedback

on leadership strengths and

areas for development.

Medical and

Dental Staff

1.5 hours £80 + Vat pp

for FMLM 360

feedback

report

6 Individual reports cost

13 Final 14/12/18

Supporting wider Leadership Development

The Leadership and OD team will support the development of future operational leaders by actively supporting the national #Proud2bOps movement a

joint initiative between NHS Improvement and DBTH. This consists of a network for the benefit of senior operational leaders in the operational delivery

environment and the wider system to enable peer support, expert ops advice to system development, identifying and nurturing talent and informing

leadership development programmes.

Leadership Networks

We will continue to promote, advertise and support the DBTH leadership networks and forums and deliver OD input as required.

National Leadership Academy

It is important to note that the DBTH Leadership and OD Team will continue to maintain strong links with The National Leadership Academy and actively

signpost staff to their programmes. They offer high quality leadership development programmes and short courses that can be accessed by our staff. Below

is an outline of the core programmes and associated costs. If leaders want to access these programmes the funding resource will need to be identified by

the budget holder, as there is not central leadership development fund. On some occasions the leadership academy offer free courses, or bursaries for

certain programmes. Within DBTH we will sign post leaders to charitable funds applications to apply for funding towards the leadership academy

programmes.

14 Final 14/12/18

15 Final 14/12/18

Sound Bites will enhance our leadership offer by creating the opportunity for short 90 minute face to face sessions for leaders

and managers. These sessions give clear messages on important topics with a strong focus upon how the leader will apply this

to their leadership practice. Sound Bites will be offered centrally in the prospectus or are portable and can be delivered in situ

to work teams upon request. There will be a range of topics delivered through a sound bite approach these will include:

Stress Awareness

Personal Resilience

Quality Appraisals

Candid Conversations

Living the We Care Values and Behaviours

Over time it is expected that the Sound Bites catalogue will expand in response to feedback and suggestions for future topics from our leaders.

Leadership and Management Apprenticeships

The Leadership and Management Apprenticeships offer an opportunity for leaders and managers to develop their leadership skills, knowledge and know‐

how whilst gaining a recognised professional qualification. We have many experienced leaders within the organisation who are looking for a formal

leadership qualification to support their career aspirations and personal development. Through the apprenticeship levy we have an opportunity to offer our

new recruits and existing workforce access to Leadership and Management formal education and study through an Apprenticeship route. These range from

Intermediate Level 2 or 3 to Higher Level 5, Degree Level 6, and Masters Level 7 Apprenticeships.

Leadership &

Management

Apprenticeships

About the programme Who it is for Time Commitment Costs £ Nos

planned

Additional Notes

Level 2 Award in

Team Leading

Framework

(ILM Level 2)

Develops knowledge of the

roles and responsibilities of a

team leader.

Practicing or aspiring

team leaders

Duration: 12 months £2k funded

from Levy

10 Provider Doncaster

College

16 Final 14/12/18

Leadership &

Management

Apprenticeships


planned

Additional Notes

Level 3 Diploma

Team

Leader/Supervisor

Framework

(ILM Level 3)

Supporting, managing and

developing team members,

managing projects, planning

and monitoring workloads and

resources. Delivering

operational plans, resolving

problems, and building

relationships.

Front Line managers,

Junior Managers,

Supervisors, Team

Leaders.

Duration: 18 months £2.5k

funded

from Levy

10 Provider Doncaster

College

Higher Level

Apprenticeship

Level 5

(Chartered

Management Institute

Diploma in

Management &

Leadership)

Designed to accelerate the

development of department

managers to maximise potential

and drive forward business

effectiveness. Learning to lead

and manage people effectively.

Start of management

career, may have

experience but not

theory. Essential that

they manage others.

Includes Discovery

Insights.

Duration: 18 months

6 workshops 2 or 3 day

blocks

£9 funded

from Levy

1‐10

(aim 6)

Provider Doncaster

College

17 Final 14/12/18

Leadership &

Management

Apprenticeships


planned

Additional Notes

Chartered

Manager Degree

Apprenticeship

Level 6

(BA Hons Professional

Practice in

Management)

Work based learning and

business education.

To establish a clear

progression route for

new recruits and

aspiring or existing

managers.

3 – 4 days per year six

times per year

Duration: Three ½ years

£27k

funded

from Levy

1 ‐ 8 Provider Open

University and

Sheffield Hallam

University

Senior Leaders

Master’s Degree

(MA) in Leadership

Practice

Level 7

MA Leadership in

Practice

(CMI Level 7 in

Strategic Management

and Leadership)

Offers multi‐disciplinary

approach to the study of

leadership. Includes Art Of

Leadership, Innovation and

Change, Intrapreneurial

Leadership and Advanced

Practice Inquiry.

For experienced

leaders with a first

degree who want to

develop their

strategic leadership

further leadership

further

Year 1 ‐ 2 x two day

modules

Year 2 ‐ 2 x two day

modules

Duration: 2 ½ years

£18k

funded

from Levy

0 ‐ 3 Provider Sheffield

Hallam University

18 Final 14/12/18

Leadership &

Management

Apprenticeships


planned

Additional Notes

Level 7 Executive

MBA

(CMI Level 7 in

Strategic

Management and

leadership)

Offers strategic business

management knowledge.

Middle and senior

managers with a first

degree or extensive

work experience.

Min 2 years

man/leadership

experience and in a

leadership role.

Yr. 1 ‐ 4 x three day

workshops and 1 day

induction

Yr. 2 ‐ 3 x three and a

half day workshops

Yr. 3 ‐ 1 x four day block,

dissertation or

consultancy project

Duration: 3 years

£18 funded

from Levy


Hallam University

Level 7 Executive

MBA Facilities

Management

(CMI Level 7 in

Strategic

Management and

leadership)

Offers strategic business

management knowledge.

Middle and senior

managers with a first

degree or extensive

work experience.

Min 2 years

man/leadership

experience and in a

leadership role.

Yr. 1 ‐ 4 x three day

workshops

Yr. 2 ‐ 3 x three ½ day

workshops

Yr. 3 – 1 x four day block

or dissertation project

Duration: 2 ½ ‐ 3 years

£18k

funded

from Levy


Hallam University

19 Final 14/12/18

2.3 Support our Teams

To support our teams we need to grow and develop our talent, we need leaders to be proactive on how they grow and develop their people. Within DBTH

we will adopt a proactive approach to the identification and development of our people. To do this we need to ensure our leaders have the skills to identify

the development needs and consider the career aspirations of their staff and teams. We will train leaders in:

Talent Conversations and the application of the Team Development Matrix

Appraisal skills for leaders and managers

Personal development planning

Coaching skills

Signposting and promoting access to informal development such as stretch assignments, project work, shadowing, buddying, mentoring, career

coaching

Presentation skills

Talent

Management

About the programme Who it is for

Time

Commitment

Costs £ Number planned Additional Notes

Talent

Management

Roll out a programme of talent

conversations training within DBTH

All leaders and

managers

90 minute

Sound Bite

20

20 Final 14/12/18

Organisational Development

We want to create a culture where our ‘We Care’ values are lived and embedded and it is ‘the way we do things around here’. We will adopt a structured

approach to Organisational Development (OD) and requests for interventions will be managed through the application of the structured OD cycle

methodology which includes entry and contracting phase, diagnostic phase, intervention and evaluation phase and close down. This will help to ensure that

the appropriate OD intervention is applied and there is a clear outcome and end point to the work.

OD Interventions may include:

Application of Psychometric instruments for recruitment and development including; Discovery Insights, The Quest Profiler, Lumina sparks

Leadership Development Feedback tools Healthcare leadership model 360 degree feedback, Faculty of Medical Managers and Leaders 360 degree

feedback

Team Building/development programmes

Targeted Leadership development Programmes; Shadow Board

Facilitation of action learning sets

Coaching

Mentoring

Mediation

Quality Improvement Interventions

CREST (Crisis Response Employee Support Team)

Sound Bites – short 90 minute development sessions on key topics

21 Final 14/12/18

2.4 Value our People

Strong leadership and engagement can and does encourage team cohesion, a sense of team optimism about work and builds a sense of efficacy. It enables

team members to feel confident in the ability of the team to achieve its goals and deliver high quality, compassionate and inspiring care. Good leaders

create a positive climate for staff so that they feel valued and that they experience a sense of belonging to an organisation and a connection with the core

business purpose. If staff feel engaged they have the emotional capacity to care for others much better.

Good leaders listen constantly and carefully in order to learn about the obstacles and hindrances that frustrate front line staff and then work with them to

overcome them. They also confront and deal decisively with those behaviours which create negativity, stress and disengagement within the team or

organisation.

To value our people and foster staff engagement we will;

Develop and nurture our staff experience forums across all 3 hospital sites

Listen and respond to staff concerns, issues and feedback

Take a proactive approach to responding to staff survey results and friend and family test results

Recognise, reward and acknowledge good performance and contribution

Celebrate long service

Deliver Health and Well‐being strategies, events and campaigns to keep our people well

Develop leadership knowledge and skills in the art of staff engagement

Celebrate positive role models with the right values and behaviours.

22 Final 14/12/18

Value Our People About the Interventions Who it is for

Time

Commitment

Costs £ Nos planned Additional

Comments

Staff Engagement A key theme in all our leadership

programmes, why and how leaders

need to engage the work force and

the benefits of doing so

All leaders and

managers

Module within

leadership

development

programme

0 40 Links with

Inclusive

leadership, EDI

Role Modelling We

Care Values and

Behaviours

How to bring to life and live the ‘We

Care’ values in everything you do will

be a consistent theme within the

leadership development

programmes

All leaders and

managers

Module within

leadership

development

programme

0 40 In all

programmes

Staff Experience Group Engage with our people through

delivery of a strategic staff

experience group once per quarter

on all 3 main hospital sites

All leaders and

managers

3 monthly

meeting by

invitation

0 4 per year All 3 hospital

sites

facilitated by

Leadership &

OD Team

Health and Wellbeing Embed health and well‐being within

Leadership training with a focus on

caring for our people

All leaders and

managers

Development

programmes

Roadshows

0 40 Health and well‐

being faculty to

deliver

23 Final 14/12/18

Value Our People About the Interventions Who it is for

Time

Commitment

Costs £ Nos planned Additional

Comments

Quality Improvement

Quality Improvement Increase number of leaders trained

in Quality Improvement methods by

embedding in and signposting QI

approaches into development

programmes

All leaders Module within

leadership

development

programme

0 40 QI in all

programmes

3.0 References

NEXT‐STEPS‐ON‐THE‐NHS‐FIVE‐YEAR‐FORWARD‐VIEW.pdf 2017

https://www.england.nhs.uk/wp‐content/uploads/2017/03/NEXT‐STEPS‐ON‐THE‐NHS‐FIVE‐YEAR‐FORWARD‐VIEW.pdf

Caring to change ‐ How compassionate leadership can stimulate innovation in health care. Authors: Michael West, Regina Eckert, Ben Collins, Rachna

Chowla May 2017

New NHS leadership framework – Developing people improving care 6 December 2016

Transformational change in health and care ‐ Reports from the field Kings Fund.

Board Development Schedule: 2019-2020

Date and Time Location Responsibility Action Update

Meeting in January 2019 Karen Barnard/Jayne Collingwood

To work with Sheena McDonnell, Pat Drake and Jayne Collingwood on the recommendations from the recent assessment for the NED and Board development and agree actions

Tuesday 29th January 2019 Doncaster Royal Infirmary Board Room

Karen Barnard/Jayne Collingwood

Non-Executive Directors and Chair to attend a Discovery Insight development session facilitated by Steve Robinson

Steve to contact Suzy before the NED session.

Tuesday 26th February 2019 Bassetlaw Hospital Board Room

Karen Barnard/Jayne Collingwood

All Board members to attend a follow up Discovery Insights Session facilitated by Steve Robinson

Gareth Jones to be included

March 2019 Simon Marsh / Robin Smith

National Cyber Security Issues to be presented by NHS Digital

Gareth working with Simon Marsh to schedule into an agenda for BoD or following the BoD Meeting.

Early March 2019 Karen Barnard/Jayne Collingwood

Launch of the HEAR Masterclass series and All Board members and Divisional Senior Leadership Teams to be invited

To be delivered by external speaker Feedback from SLTs is that Masterclass session would best run 4 – 6pm. Quarterly session will run July, September and February 2020.

March 2019 Jayne Collingwood A one day board development workshop exploring how to get the balance between support and challenge ensuring good scrutiny occurs. Exploring questioning, probing and challenging skills especially outside own areas of expertise.

Jayne Collingwood to source facilitator

April 2019 David Purdue Presentation to be given to board on the work in theatres and outpatients

Gareth to schedule

May 2019 Simon Marsh Workshop on Digitising Accident and Emergency Gareth to schedule

May 2019 Jayne Collingwood Exploration of the Trust’s values and behaviours of and the development of a code of conduct (NB reference to the code developed with the governors)

Date and Time Location Responsibility Action Update

June 2019 Karen Barnard/Jayne Collingwood

Launch Shadow Board Programme to give exposure to Aspirant Directors to the role of Board members and functions of the board

To work with Leadership Academy to set up and deliver this programme

July 2020 Marie Purdue LEAN principles development session Gareth to schedule

September 2020 Karen Barnard/Anthony Jones

Workshop on Values Based Recruitment Gareth to schedule

October 2020 Karen Barnard Review of Board development action plan

Title Chair’s and NEDs’ Report

Report to Board of Directors Date 18 December 2018

Author Suzy Brain England, Chair of the Board


Decision

Assurance

Information x


The report covers the Chair and NEDs’ work in November and December 2018


N/A


The report relates to all of the strategic objectives.


N/A


That the report be noted.

Chair’s and NEDs’ Report – December 2018

This month I had the pleasure of meeting with the Trust volunteers, a very special group of people who generously donate their free time to support patients, visitors and staff across all three of our hospital sites. In order to show our appreciation volunteers were invited to a celebratory festive brunch held in the Boardroom at Doncaster Royal Infirmary and Bassetlaw Hospital. Both events were well attended and supported by a range of Trust staff, including executive and non-executive directors. It was a

great opportunity to express my thanks, personally and on behalf of the Trust, for the invaluable service they provide. Colleagues were able to hear first-hand of the volunteers’ experiences, examples of where things go well and where perhaps there is room for improvement. From discussions at the gatherings a need for effective two way communication was identified and we are committed to ensure an appropriate mechanism is put in place to facilitate this. Following a recent meeting with Suzanne Bolam, Head of Therapies, I was invited to welcome delegates to a bespoke Leadership Course for band 6 Therapists and Allied Health Professionals, The course, co-developed by Christine White, Senior People and Business Partner and Aimi Dillon, Education Lead runs alongside the Insights discovery programme and provides colleagues with an opportunity to develop their leadership skills to ensure a resilient, fit for purpose, innovative workforce for the future. I was able to share with them my passion for staff development and hope to be able to play a part in future sessions where my diary allows. December is always a busy month and this year has been no exception, I have been involved in a variety of official duties. The Chairman of Bassetlaw District Council, Councillor David Challinor was welcomed to Bassetlaw Hospital, by myself, Kate Carville, Associate Director of Nursing and The Reverend Simon Russell. Councillor Challinor was able to tour a number of wards/departments.

Later that same week the Civic Mayor of Doncaster, Councillor Majid Khan visited both our Doncaster and Montagu sites. Our clinical Non-executive Director, Pat Drake supported the tour at Montagu where Councillor Khan visited the Fred & Ann Green Rehabilitation Centre and the Clinical Simulation Centre. Commitments don’t always allow me to attend each and every event and I am grateful for the support of my colleagues at this time. I understand that I missed out on a truly magical performance by the pupils of Norbridge Academy following the Bassetlaw light switch on which Karen Barnard, Director of People & Organisational Development attended on my behalf. Governor Meetings Jon Sargeant, Director of Finance, spoke at this month’s governors’ briefing, his presentation provided colleagues with an overview of the capital governance and planning process, including Estates’ five year capital plan and backlog maintenance. Unfortunately, due to limited numbers of confirmed attendees a decision was made to stand down the governor timeout session planned for 13 December and colleagues who had been due to present will be rescheduled in 2019. I recognise that December is a busy time of year for everyone and this was probably not well timed on our part; Gareth Jones, Trust Board Secretary, has agreed to review the 2019 governor meeting schedule for appropriateness. NED Reports Alan Chan Alan was delighted to be able to join Suzy at the Volunteers Festive Brunch at Doncaster Royal Infirmary on 3 December. It was an excellent opportunity to meet colleagues and express his gratitude for their unfaltering support. The event was very well attended and from the feedback received it was clear that the volunteers were truly grateful that their contribution was recognised in this way. Kath Smart Kath has continued her buddying arrangements this month, meeting with the Medicine Division and attending their divisional meeting to better understand their performance, challenges and risks. She attended a meeting with Internal Audit to finalise the Committee Effectiveness Audit report, along with the Chair of the Board and the Finance and Performance and Quality and Effectiveness Committee Chairs. Thinking of her well-being and that of others whilst on her many site visits Kath ensured she received her flu jab, which was administered by the Chief Executive himself!

And finally, looking from a different perspective as a service user, Kath has been able to report two positive patient experiences in the Orthopaedic Clinical Triage Assessment and Treatment Service and the X-ray department. Pat Drake Since providing her last update Pat has attended a variety of Trust meetings, Governor Brief, Council of Governors and the Appointments and Remunerations Committee where she presented a paper in her capacity as Senior Independent Director (SID). Pat attended a NHS Providers roundtable discussion on the relationship between the arts and health, and how this can support the future sustainability of the NHS. She subsequently met with Karen Barnard, Director of People and Organisational Development to discuss the national document which considers the ways in which engagement in the arts can have a positive impact on health. As Freedom to Speak Up (FTSU) NED Pat has met with Lyn Goy, FTSU Guardian to discuss her current work and future plans. She has also had the opportunity to speak to Sam Debbage, Deputy Director of Education, to discuss non-medical training and education and the strategy to support this. As clinical NED Pat continues to have a presence across the hospital and has recently visited the Department of Critical Care, the Integrated Discharge Team and the surgical wards. Finally, this month Pat has supported the visit of the Civic Mayor, Councilor Majid Khan on his tour of Montagu, supported by Janice Edees, Steve Wells and Nicki Sherburn. Linn Phipps This month Linn has chaired a consultant interview panel for Acute Medicine. Following her passion for singing, Linn has joined the Trust’s choir and will be supporting a number of events this month including the League of Friends service at Bassetlaw and the performance of the choir at Gate 4 on Tuesday 18 December. Neil Rhodes Since the last Chair’s update Neil has attended a Board of Directors meeting at Bassetlaw, took part in a Nominations and Remuneration Committee and met with other Committee Chairs and our internal auditors in relation to Committee Effectiveness. On 4 December he joined the Chair of the Board at a lunch to thank our volunteers at Bassetlaw Hospital – which was a really rewarding experience. Neil also met with Deputy Chief Operating Officer, Emma Challans, to discuss a pioneering initiative to work more effectively with the Her Majesty’s Prison Service and will now take a continuing interest in that work.

On 12 December he visited the Intensive Care Unit with Pat Drake and had a tour of the innovative Ambulatory Care Surgical Assessment facility. In addition he met with Mandy Espey, General Manager of the Surgery and Cancer division to better understand the divisional structure and practices and also took the opportunity to attend the daily Trust wide Bed Assessment Meeting. Finally, he has held a 1-2-1 meeting with the Director of Finance, Jon Sargeant, in relation to financial planning and performance management and also chaired a Finance and Performance planning meeting. Sheena McDonnell This month Sheena has attendance the Quality and Effectiveness Committee and Board of Directors; she has developed a presentation on holding to account, which will be delivered at the rescheduled Governor time out session in the New Year. Sheena has also chaired the Ophthalmologist Consultant interview panel and has contributed to breast screening awareness, particularly around encouraging attendance at screening appointments.

Chief Executive’s Report

18 December 2018

The effects of banning Fax Machines at DBTH by 2020

In a recent article the Department of Health has said that the NHS is to ban the

use of fax machines by 2020 and should use secure email instead. A recent study

in July 2018 by the Royal College of Surgeons revealed that nearly 9,000 fax

machines were still in use across the NHS in England.

In October, DBTH received or sent nearly 30,000 faxes of which 24,000 of these are to or from

external numbers and the remaining 6,000 faxed internal to internal machines. It is acknowledged

that further work is required to analyse the number for inbound calls to better understand the

calling data.

DBTH has a plan in place with workflow and e-forms that are associated with the Electronic Patient

Record (EPR) developments. A workshop for the Executive Team including Divisional Directors took

place on Wednesday 12 December 2018.

To achieve the full elimination of fax machines by 2020 will be challenging. Board should be aware of

other deadlines pending for 2020 to include EPR, SNOMED and GS1 compliance which will need to

be reflected in the work to eliminate fax machines.

Knowledge, Library & Information Service

The Trust’s Library and Knowledge Service have again been recognised by

Health Education England for their high standards of service.

Assessed against the NHS Library Quality Assurance Framework (LQAF) the

team, led by Janet Sampson, have achieved 100% compliance with the national standards, a level

they have maintained since 2016. The Trust joins only ten other library services in the North of

England to achieve this level of compliance from a possible 61.

The support offered by the team is invaluable to colleagues and I would like to congratulate each

and every one of them for their hard work and dedication. Janet retires from her post as Service

Manager on 20 December, and on behalf of the Trust I would like to wish her a very long and happy

retirement.

Trust’s Commitment to Organ Donation and Transplantation in the UK

NHS Blood and Transplant (NHSBT) have reported a record year for organ

donation and transplantation in 2017/18, with 4039 patients in the UK having

received a life-saving or life-changing solid organ transplant.

This excellent performance has continued into the first six months of 2018/19 with a 4% increase

noted as compared to the same period in 2017/18. Feedback from NHSBT identified that our Trust,

during the period April to September 2018, facilitated four actual solid organ donors from four

consented donors, this resulted in 12 patients receiving a transplant during this period.

In addition, we referred 11 patients to NHSBT’s organ donation service, all of which met the referral

criteria and were included in the UK Potential Donor Audit. A specialist nurse supported 100% of

family discussions with potential donors.

NHS Executive Group

NHS England and NHS Improvement have this month announced their new

joint senior leadership team – the NHS Executive Group.

Appointments were recognised as an important milestone in securing closer

working arrangements between the two organisations. In terms of leadership,

Simon Stevens and Ian Dalton will remain as Chief Executives of NHSE and NHSI respectively, while at

a regional level, Richard Barker, currently NHSE’s director for the North of England will take up the

position of NHS North East and Yorkshire Regional Director.

The regional directors will support the development and identity of sustainability and

transformation partnerships and integrated care systems, and will be responsible for proactively

sharing learning from local areas across the national health and care system.

New Macmillan ‘Pod’ opens at Doncaster Royal Infirmary

With our partners at Macmillan Cancer Support and Rotherham Doncaster and

South Humber NHS Foundation Trust (RDaSH), we have opened a ‘Pod’ within

our Outpatients department.

The pod, which will provide support, information and advice, has been funded

by Macmillan Cancer Support, a charity which helps people affected by cancer through their

journeys. While the facility is now open to the public, further work is ongoing to build consultation

rooms and will be fully launched in January 2019.

The new centre provides a friendly, private environment for patients, carers and family members

affected by cancer, to access appropriate information and support, from managing symptoms to

advice on benefits and financial support, the pod can provide expert help and has a wide-range of

Macmillan booklets to take away.

The Chequer Road Clinic is on the move

In the coming months, services provided by Doncaster and Bassetlaw

Teaching Hospitals will be moving from the Chequer Road Clinic. There are a

number of reasons for the move, most of which are related to the make-up of

the building itself rather than any need for maintenance or repair.

As technology and patient demand increases, the Chequer Road Clinic is no longer ideal. One such example is audiology tests - which, due to the complexity of modern diagnostics, too often have to be cancelled due to the building’s flat roof and the sound created when it rains. This in turn causes huge inefficiencies, as well as an impact on patient care and treatment, and we believe we can provide a better service elsewhere, in a building more suited to our needs.

Rest assured, Audiology, Children’s Speech and Language Therapy, Breast Screening and other services at the clinic will continue to be provided for local people and we are currently in the process of securing new premises nearby. We are currently in talks with our partners at the Council and CCG, and we will be able to confirm the new premises as soon as we have an agreement in place. In the meantime, we are advising patients with appointments at Chequer Road Clinic to attend as usual.

A ‘thank you’ for kind donations

As we head towards Christmas, I have been struck by the generosity of the

communities we serve. The Trust has already received numerous donations

within our wards and services and for this I want to say thank you to those

individuals, families and organisations who have decided to support their local

hospitals this Christmas.

1

As at 12 December 2018

Board of Directors Agenda Calendar

STANDING ITEMS OTHER / AD HOC ITEMS

MONTHLY QUARTERLY BIANNUAL / ANNUAL

FEBRUARY 2019

CE Report QEC Minutes Budget Setting / Business Planning / Annual Plan

Finance Strategy

Performance Report Board Assurance Framework & corporate risk register Q3

MB Minutes

HWB Decision Summary

Finance & Performance Minutes

Finance Report

DECEMBER 2018

CE Report

Performance Report

MB Minutes


Finance Report

Chairs’ Assurance Logs

JANUARY 2019

CE Report ANCR minutes (16.12.16) Budget Setting / Business Planning / Annual Plan

Constitution

Performance Report Executive Team’s Objectives SOs, SFI, Scheme of Delegation CT/HASU (part 2)

MB Minutes Complaints, Compliments, Concerns and Comments Report

Joint working


QEC minutes External reviews policy

Finance Report Estates Quarterly Performance Estates Visit

Chairs’ Assurance Logs WOS

EPR Business Case – Simon Marsh

2



MARCH 2019

CE Report Report from the Chair of the ANCR committee (Verbal)

Budget Setting / Business Planning / Draft Annual Plan

Presentation – Data Security Protection (Presentation Slot P1 – Roy Underwood)

Performance Report

MB Minutes

HWB Decision Summary


Finance Report


APRIL 2019

CE Report ANCR minutes Draft Annual Report Mandatory training update

Performance Report Executive Team’s Objectives Draft Quality Account

MB Minutes Estates Annual Report Staff Survey

HWB Decision Summary Board Assurance Framework & corporate risk register Q4 (inc. annual assurance summary)


Finance Report


MAY 2019

CE Report QEC Minutes Annual Report

Performance Report Quality Account

MB Minutes Annual accounts

HWB Decision Summary ISA260 and quality account assurance


Charitable Funds minutes

3


Finance Report Mixed Sex Accommodation


JUNE 2019

CE Report

Performance Report

MB Minutes


Finance Report


JULY 2019

CE Report ANCR Minutes ANCR Annual Report

Performance Report Estates Quarterly Performance

MB Minutes Board Assurance Framework


Finance Report


AUGUST 2019

CE Report QEC minutes Health and Wellbeing

Performance Report ANCR Minutes Missed Appointments

MB Minutes Executive Team Objectives


Finance Report


4


SEPTEMBER 2019

CE Report Winter Plan

Performance Report EPPR

MB Minutes Annual Compliance against the National Core Standards for Emergency Preparedness, Resilience and Response (EPRR)


Finance Report


OCTOBER 2019

CE Report ANCR minutes Charitable Funds minutes

Performance Report Executive Team’s Objectives

MB Minutes


Finance Report


NOVEMBER 2019

CE Report Board Assurance Framework & corporate risk register Q2

P&OD Update

Performance Report Brexit Preparations

MB Minutes


Finance Report


ANCR Minutes

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